Provider Demographics
NPI:1033983507
Name:IMPERIAL, JACK LEANDER (BT)
Entity Type:Individual
Prefix:
First Name:JACK LEANDER
Middle Name:
Last Name:IMPERIAL
Suffix:
Gender:M
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 W. BOB-O-LINK RD.
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056
Mailing Address - Country:US
Mailing Address - Phone:224-500-5955
Mailing Address - Fax:
Practice Address - Street 1:3030 W SALT CREEK LN STE 350
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-5000
Practice Address - Country:US
Practice Address - Phone:877-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician