Provider Demographics
NPI:1336479278
Name:JAI YESU PSYCHIATRIC SERVICES SC
Entity Type:Organization
Organization Name:JAI YESU PSYCHIATRIC SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-467-3615
Mailing Address - Street 1:4711 N LAPORTE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3830
Mailing Address - Country:US
Mailing Address - Phone:540-467-3615
Mailing Address - Fax:
Practice Address - Street 1:4711 N LAPORTE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3830
Practice Address - Country:US
Practice Address - Phone:540-467-3615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-27
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1212032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty