MEDICARE: JACKIE GOLLAN 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	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1841383007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE GOLLAN PHD

Provider Business Mailing Address
First Line	:	680 N LAKE SHORE DR
Second Line	:	SUITE 1000
City	:	CHICAGO
State	:	IL
Zip	:	60611-4546
Country	:	US
Telephone Number	:	312-695-9797
Fax Number	:

Provider Business Practice Location Address
First Line	:	446 E ONTARIO ST
Second Line	:	SUITE 7-100
City	:	CHICAGO
State	:	IL
Zip	:	60611-4418
Country	:	US
Telephone Number	:	312-695-5060
Fax Number	:

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/08/2007

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