Provider Demographics
NPI:1558490433
Name:POWITZ, JACK N (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:N
Last Name:POWITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4700 N WESTERN AVE
Mailing Address - Street 2:STE. 1B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2081
Mailing Address - Country:US
Mailing Address - Phone:773-334-8580
Mailing Address - Fax:773-334-8590
Practice Address - Street 1:4700 N WESTERN AVE
Practice Address - Street 2:STE. 1B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2081
Practice Address - Country:US
Practice Address - Phone:773-334-8580
Practice Address - Fax:773-334-8590
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry