Provider Demographics
NPI:1083701429
Name:HISAW, JEREMY BROOK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:BROOK
Last Name:HISAW
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 1:1733 W CRYSTAL ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-8801
Mailing Address - Country:US
Mailing Address - Phone:773-403-0473
Mailing Address - Fax:
Practice Address - Street 1:1 E SUPERIOR ST
Practice Address - Street 2:SUITE #310
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2507
Practice Address - Country:US
Practice Address - Phone:773-403-0473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
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
IL1636404OtherBC/BS PROVIDER NUMBER