Provider Demographics
NPI:1235879990
Name:WICKHAM, JOHN B
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 W SUNNYSIDE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5684
Mailing Address - Country:US
Mailing Address - Phone:773-388-1600
Mailing Address - Fax:773-388-8936
Practice Address - Street 1:3948 N SHERIDAN RD STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2935
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:773-388-8936
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0242441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.024244Medicaid