MEDICARE: MR. JESSE PATRICK WALTZ MAED, LMFT

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	106H00000X	Marriage & Family Therapist	104021	KY
2	106H00000X	Marriage & Family Therapist	166.001334	IL

General Provider Information

NPI Number	:	1619313988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESSE PATRICK WALTZ MAED, LMFT

Provider Business Mailing Address
First Line	:	PO BOX 204
Second Line	:
City	:	PLAINFIELD
State	:	IL
Zip	:	60544-0204
Country	:	US
Telephone Number	:	270-312-7752
Fax Number	:

Provider Business Practice Location Address
First Line	:	8658 S SACRAMENTO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-3800
Country	:	US
Telephone Number	:	773-962-3740
Fax Number	:

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

Provider Enumeration Date	:	05/14/2013
Last Update Date	:	08/27/2024

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