MEDICARE: MRS. JACQUELINE HERBSTMAN LCSW

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	1041C0700X	Clinical Social Worker	212431	MA
2	1041C0700X	Clinical Social Worker	149013810	IL

General Provider Information

NPI Number	:	1588725873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELINE HERBSTMAN LCSW

Provider Business Mailing Address
First Line	:	3133 N LAKEWOOD AVE
Second Line	:	APT. 4F
City	:	CHICAGO
State	:	IL
Zip	:	60657-9459
Country	:	US
Telephone Number	:	312-307-9887
Fax Number	:

Provider Business Practice Location Address
First Line	:	1770 W BERTEAU AVE
Second Line	:	SUITE 302A
City	:	CHICAGO
State	:	IL
Zip	:	60613-1849
Country	:	US
Telephone Number	:	312-307-9887
Fax Number	:

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	10/30/2015

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