MEDICARE: JILLIAN TAYLOR CLARKE 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	149.014177	IL

General Provider Information

NPI Number	:	1659637601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLIAN TAYLOR CLARKE LCSW

Provider Business Mailing Address
First Line	:	2432 W LUNT AVE # B3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-4602
Country	:	US
Telephone Number	:	309-678-4413
Fax Number	:

Provider Business Practice Location Address
First Line	:	3166 N LINCOLN AVE STE 214A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3119
Country	:	US
Telephone Number	:	309-678-4413
Fax Number	:

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

Provider Enumeration Date	:	04/04/2012
Last Update Date	:	04/04/2012

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