Provider Demographics
NPI:1033269535
Name:COX, JACK GERARD (MSW)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:GERARD
Last Name:COX
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2723 THAYER ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1344
Mailing Address - Country:US
Mailing Address - Phone:847-864-8938
Mailing Address - Fax:
Practice Address - Street 1:456 W FRONTAGE RD
Practice Address - Street 2:SUITE 28
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3034
Practice Address - Country:US
Practice Address - Phone:847-220-2224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01636627OtherBLUECROSSBLUESHIELD
IL591990Medicare ID - Type UnspecifiedMEDICARE PART B PROVIDER