Provider Demographics
NPI:1629377882
Name:JON-PAUL CHAMPINE, PSY.D., P.C.
Entity Type:Organization
Organization Name:JON-PAUL CHAMPINE, PSY.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON-PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPINE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-869-4650
Mailing Address - Street 1:2530 CRAWFORD AVE
Mailing Address - Street 2:SUITE 315
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4970
Mailing Address - Country:US
Mailing Address - Phone:847-869-4650
Mailing Address - Fax:773-751-2250
Practice Address - Street 1:2530 CRAWFORD AVE
Practice Address - Street 2:SUITE 315
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4970
Practice Address - Country:US
Practice Address - Phone:847-869-4650
Practice Address - Fax:773-751-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006739103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210025Medicare Oscar/Certification