Provider Demographics
NPI:1265864797
Name:JACK, ANDREW SCOTT (MA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:SCOTT
Last Name:JACK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1N002 BARRY AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-2920
Mailing Address - Country:US
Mailing Address - Phone:630-779-0974
Mailing Address - Fax:
Practice Address - Street 1:7 BLANCHARD CIR STE 201
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-2039
Practice Address - Country:US
Practice Address - Phone:630-653-2300
Practice Address - Fax:630-653-2895
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional