Provider Demographics
NPI:1447394135
Name:GRYGOTIS, JACQUELINE H (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:H
Last Name:GRYGOTIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 JUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1320
Mailing Address - Country:US
Mailing Address - Phone:847-204-4172
Mailing Address - Fax:847-328-7772
Practice Address - Street 1:1021 JUDSON AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1320
Practice Address - Country:US
Practice Address - Phone:847-204-4172
Practice Address - Fax:847-328-7772
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0053711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical