Provider Demographics
NPI:1124190335
Name:JANE ADDAMS COMMUNITY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:JANE ADDAMS COMMUNITY MENTAL HEALTH CENTER
Other - Org Name:FHN FAMILY COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VPOF PATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-599-7529
Mailing Address - Street 1:PO BOX 813
Mailing Address - Street 2:421 W EXCHANGE ST.
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 1:421 W EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4030
Practice Address - Country:US
Practice Address - Phone:815-599-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL635500Medicare PIN