Provider Demographics
NPI:1437494127
Name:CHAN, JIMMY (LCSW, LPHA)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:LCSW, LPHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3062 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3062 E 91ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4401
Practice Address - Country:US
Practice Address - Phone:773-371-2925
Practice Address - Fax:773-371-2950
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490122811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical