MEDICARE: DR. WILLIAM JOSEPH JEDLICKA PHD

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	103T00000X	Psychologist		IL

General Provider Information

NPI Number	:	1659566420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM JOSEPH JEDLICKA PHD

Provider Business Mailing Address
First Line	:	7 SHORELINE RD
Second Line	:
City	:	LAKE BARRINGTON
State	:	IL
Zip	:	60010-1621
Country	:	US
Telephone Number	:	312-382-9139
Fax Number	:

Provider Business Practice Location Address
First Line	:	7 SHORELINE RD
Second Line	:
City	:	LAKE BARRINGTON
State	:	IL
Zip	:	60010-1621
Country	:	US
Telephone Number	:	312-382-9139
Fax Number	:

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

Provider Enumeration Date	:	09/13/2007
Last Update Date	:	09/13/2007

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