MEDICARE: IMANI JACQUET

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1477222065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMANI JACQUET

Provider Business Mailing Address
First Line	:	6124 N WINTHROP AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-2663
Country	:	US
Telephone Number	:	832-671-3268
Fax Number	:

Provider Business Practice Location Address
First Line	:	6124 N WINTHROP AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-2663
Country	:	US
Telephone Number	:	832-671-3268
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2021
Last Update Date	:	09/08/2021

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Directions to “ IMANI JACQUET ” Practice Location

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