MEDICARE: DR. JASON J. WASHBURN PH.D., ABPP

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	103G00000X	Clinical Neuropsychologist	071006568	IL
2	103T00000X	Psychologist	071006568	IL
3	103TB0200X	Cognitive & Behavioral Psychologist	071006568	IL
4	103TC2200X	Clinical Child & Adolescent Psychologist	071006568	IL

General Provider Information

NPI Number	:	1962628586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON J. WASHBURN PH.D., ABPP

Provider Business Mailing Address
First Line	:	3047 N LINCOLN AVE
Second Line	:	SUITE #400
City	:	CHICAGO
State	:	IL
Zip	:	60657-4999
Country	:	US
Telephone Number	:	773-904-0445
Fax Number	:

Provider Business Practice Location Address
First Line	:	3047 N LINCOLN AVE
Second Line	:	SUITE #400
City	:	CHICAGO
State	:	IL
Zip	:	60657-4999
Country	:	US
Telephone Number	:	773-904-0445
Fax Number	:

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/09/2011

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