MEDICARE: JMS BEHAVIORAL HEALTH SERVICES, LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01632842	OTHER	IL	BLUE CROSS BLUE SHIELD OF ILLINOIS

General Provider Information

NPI Number	:	1740455567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JMS BEHAVIORAL HEALTH SERVICES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 478920
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-8920
Country	:	US
Telephone Number	:	773-786-2514
Fax Number	:

Provider Business Practice Location Address
First Line	:	2363 N CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2939
Country	:	US
Telephone Number	:	773-786-2514
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JOSEPHINE DELIRA
Credential	:	LCSW
Telephone Number	:	773-786-2514

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	04/23/2008

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