Provider Demographics
NPI:1225415623
Name:TAUB, JACQUELINE (LSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TAUB
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 N CLARK ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4614
Mailing Address - Country:US
Mailing Address - Phone:248-909-1183
Mailing Address - Fax:
Practice Address - Street 1:3139 N LINCOLN AVE
Practice Address - Street 2:#209
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3114
Practice Address - Country:US
Practice Address - Phone:312-519-3187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.015611101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health