Provider Demographics
NPI:1073127148
Name:JANE ADDAMS
Entity Type:Organization
Organization Name:JANE ADDAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MAZZARISI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-599-7935
Mailing Address - Street 1:PO BOX 813
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-0813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3001 HIGHLAND VIEW DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6942
Practice Address - Country:US
Practice Address - Phone:815-599-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JANE ADDAMS COMMUNITY MENTAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)