Provider Demographics
NPI:1164751590
Name:JAKSA, PETER (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:JAKSA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 814
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-372-4824
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 814
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-372-4824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL 071004318103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical