Provider Demographics
NPI:1700865128
Name:JACOB, KATHLEEN CALLAGHAN (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CALLAGHAN
Last Name:JACOB
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 N NEW ENGLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3301
Mailing Address - Country:US
Mailing Address - Phone:630-534-5313
Mailing Address - Fax:
Practice Address - Street 1:935 CURTISS ST
Practice Address - Street 2:SUITE 7
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-4763
Practice Address - Country:US
Practice Address - Phone:773-787-7763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490058431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621910OtherBLUE CROSS BLUE SHIELD
IL01621910OtherBLUE CROSS BLUE SHIELD