Provider Demographics
NPI:1609235365
Name:COULTAS, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:COULTAS
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 1:671 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-6101
Mailing Address - Country:US
Mailing Address - Phone:847-782-4237
Mailing Address - Fax:
Practice Address - Street 1:671 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-6101
Practice Address - Country:US
Practice Address - Phone:847-782-4237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker