Provider Demographics
NPI:1003343096
Name:ROMAN, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:ROMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 DAKOTA ST STE A
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3744
Mailing Address - Country:US
Mailing Address - Phone:815-334-5018
Mailing Address - Fax:815-356-1104
Practice Address - Street 1:650 DAKOTA ST STE A
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3744
Practice Address - Country:US
Practice Address - Phone:815-334-5018
Practice Address - Fax:815-356-1104
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL1490237411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health