MEDICARE: MR. JEROME PIETRUSIAK LICENSED CLINICAL SO

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	104100000X	Social Worker	149002241	IL
2	1041C0700X	Clinical Social Worker	149.002241	IL

General Provider Information

NPI Number	:	1679793913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEROME PIETRUSIAK LICENSED CLINICAL SO

Provider Business Mailing Address
First Line	:	2105 SUNNYSIDE
Second Line	:
City	:	WESTCHESTER
State	:	IL
Zip	:	60154-5205
Country	:	US
Telephone Number	:	708-562-9070
Fax Number	:	708-562-9073

Provider Business Practice Location Address
First Line	:	3456 W FRANKLIN BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-1308
Country	:	US
Telephone Number	:	773-533-6013
Fax Number	:

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

Provider Enumeration Date	:	04/27/2007
Last Update Date	:	12/26/2019

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