Provider Demographics
NPI:1407857873
Name:JOCK, CRAIG WHITNEY (PSYD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:WHITNEY
Last Name:JOCK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 N OAK PARK AVE
Mailing Address - Street 2:PSYCHOLOGY DEPARTMENT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1417
Mailing Address - Country:US
Mailing Address - Phone:773-794-3777
Mailing Address - Fax:
Practice Address - Street 1:4200 N OAK PARK AVE
Practice Address - Street 2:PSYCHOLOGY DEPARTMENT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-1417
Practice Address - Country:US
Practice Address - Phone:773-794-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006927103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633897OtherBLUE CROSS BLUE SHIELD #
IL32-0084889OtherGROUP TAX ID NUMBER
IL1633897OtherBLUE CROSS BLUE SHIELD #
ILK28279Medicare UPIN