Provider Demographics
NPI:1164184214
Name:KANE, JACK PATRICK JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:PATRICK
Last Name:KANE
Suffix:JR
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 1:24241 S CREE DR
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-3203
Mailing Address - Country:US
Mailing Address - Phone:630-675-4612
Mailing Address - Fax:
Practice Address - Street 1:9697 191ST ST
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8609
Practice Address - Country:US
Practice Address - Phone:630-646-6559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490199191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical