Provider Demographics
NPI:1093806614
Name:BLAINE, JEFFREY N (LCSW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:N
Last Name:BLAINE
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 1:803 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1421
Mailing Address - Country:US
Mailing Address - Phone:312-656-5361
Mailing Address - Fax:312-558-1570
Practice Address - Street 1:20 N CLARK ST
Practice Address - Street 2:SUITE 2650
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-4109
Practice Address - Country:US
Practice Address - Phone:312-558-1573
Practice Address - Fax:312-558-1570
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
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