MEDICARE: JEFFREY THOMAS ICIEK M.S.W.

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1659646644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY THOMAS ICIEK M.S.W.

Provider Business Mailing Address
First Line	:	5200 LANKERSHIM BLVD
Second Line	:	STE. 170
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91601-3155
Country	:	US
Telephone Number	:	818-980-3200
Fax Number	:

Provider Business Practice Location Address
First Line	:	5200 LANKERSHIM BLVD
Second Line	:	STE. 170
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91601-3155
Country	:	US
Telephone Number	:	818-980-3200
Fax Number	:

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

Provider Enumeration Date	:	03/09/2012
Last Update Date	:	03/09/2012

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