Provider Demographics
NPI:1417228719
Name:COLEMAN, JADE (MA, MHP)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MA, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W 33RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6647
Mailing Address - Country:US
Mailing Address - Phone:773-416-5233
Mailing Address - Fax:
Practice Address - Street 1:901 W 33RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-6647
Practice Address - Country:US
Practice Address - Phone:773-416-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL174400000XMedicaid
IL101Y00000XMedicaid
IL103K00000XMedicaid