Provider Demographics
NPI:1598817587
Name:GOLDSMITH, JEAN B (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:B
Last Name:GOLDSMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2652 W COYLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-3215
Mailing Address - Country:US
Mailing Address - Phone:773-973-0540
Mailing Address - Fax:773-973-4136
Practice Address - Street 1:2652 W COYLE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-3215
Practice Address - Country:US
Practice Address - Phone:773-973-0540
Practice Address - Fax:773-973-4136
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S18939Medicare UPIN