MEDICARE: JACKIE THE SOCIAL WORKER

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1639922396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKIE THE SOCIAL WORKER

Provider Business Mailing Address
First Line	:	4422 N RAVENSWOOD AVE # 1016
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5803
Country	:	US
Telephone Number	:	773-217-8662
Fax Number	:	888-690-5661

Provider Business Practice Location Address
First Line	:	4422 N RAVENSWOOD AVE # 1016
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5803
Country	:	US
Telephone Number	:	773-217-8662
Fax Number	:	888-690-5661

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	MRS. JACKELINE ELIZABETH MITCHELL
Credential	:	LCSW
Telephone Number	:	773-217-8662

Provider Enumeration Date	:	04/10/2024
Last Update Date	:	04/10/2024

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Directions to “JACKIE THE SOCIAL WORKER ” Practice Location

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