Provider Demographics
NPI:1033765326
Name:BURNETT, JASON MAURICE (LCSW)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MAURICE
Last Name:BURNETT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 DES PLAINES AVE APT 404
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2146
Mailing Address - Country:US
Mailing Address - Phone:312-342-7504
Mailing Address - Fax:
Practice Address - Street 1:1029 DES PLAINES AVE APT 404
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2146
Practice Address - Country:US
Practice Address - Phone:312-342-7504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490213281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical