Provider Demographics
NPI:1689148983
Name:JOKUBAUSKAS, PETER RICHARD
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:RICHARD
Last Name:JOKUBAUSKAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 WINTREE LN
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1545
Mailing Address - Country:US
Mailing Address - Phone:815-355-6977
Mailing Address - Fax:
Practice Address - Street 1:21000 S FRANKFORT SQUARE RD STE D
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-9386
Practice Address - Country:US
Practice Address - Phone:815-469-1500
Practice Address - Fax:815-220-5619
Is Sole Proprietor?:No
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician