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NPI Code Detail

MEDICARE: JONATHAN CAVANAUGH

MEDICARE: JONATHAN CAVANAUGH
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
1101YP2500XProfessional Counselor180.008799IL

General Provider Information

NPI Number : 1629374202
Entity Type Code : Individual
Provider Name (Legal Business Name) : JONATHAN CAVANAUGH
Provider Business Mailing Address
First Line : 12145 WESTERN AVE
Second Line :
City : BLUE ISLAND
State : IL
Zip : 60406-1387
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 12145 WESTERN AVE
Second Line :
City : BLUE ISLAND
State : IL
Zip : 60406-1387
Country : US
Telephone Number : 773-432-6236
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/31/2011
Last Update Date : 12/23/2014

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Directions to “ JONATHAN CAVANAUGH ” Practice Location

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