Provider Demographics
NPI:1073801189
Name:WELCH, MARY JANE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:WELCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3706
Mailing Address - Country:US
Mailing Address - Phone:312-942-3112
Mailing Address - Fax:312-942-2874
Practice Address - Street 1:2150 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3706
Practice Address - Country:US
Practice Address - Phone:312-942-3112
Practice Address - Fax:312-942-2874
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-002406364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult