Provider Demographics
NPI:1518033869
Name:SWEET, JERRY J (PHD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:J
Last Name:SWEET
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 DAVIS ST STE 160
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3664
Mailing Address - Country:US
Mailing Address - Phone:847-425-6400
Mailing Address - Fax:847-425-6408
Practice Address - Street 1:909 DAVIS ST STE 160
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-425-6400
Practice Address - Fax:847-425-6408
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002626103T00000X, 103TB0200X, 103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R20836Medicare UPIN