Provider Demographics
NPI:1578183224
Name:RAWL, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:RAWL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 JORIE BLVD STE 172
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-4409
Mailing Address - Country:US
Mailing Address - Phone:630-974-6602
Mailing Address - Fax:
Practice Address - Street 1:1100 JORIE BLVD STE 172
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-4409
Practice Address - Country:US
Practice Address - Phone:630-974-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0850082582084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty