Provider Demographics
NPI:1568454700
Name:CHICAGO DEPARTMENT OF PUBLIC HEALTH
Entity Type:Organization
Organization Name:CHICAGO DEPARTMENT OF PUBLIC HEALTH
Other - Org Name:CDPH
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF REVENUE
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAI
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-747-9443
Mailing Address - Street 1:333 S STATE ST
Mailing Address - Street 2:#200 CHICAGO DEPARTMENT OF PUBLIC HEALTH
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3900
Mailing Address - Country:US
Mailing Address - Phone:312-747-9443
Mailing Address - Fax:312-747-9447
Practice Address - Street 1:641 W 63RD ST
Practice Address - Street 2:ENGLEWOOD MENTAL HEALTH CENTER GROUND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2032
Practice Address - Country:US
Practice Address - Phone:312-747-7496
Practice Address - Fax:312-747-3674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)