Provider Demographics
NPI:1356848600
Name:REBOLLEDO, JOSE IRNE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:IRNE
Last Name:REBOLLEDO
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 1:1242 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1055
Mailing Address - Country:US
Mailing Address - Phone:312-451-1896
Mailing Address - Fax:
Practice Address - Street 1:5730 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-1580
Practice Address - Country:US
Practice Address - Phone:773-413-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health