Provider Demographics
NPI:1760609143
Name:CAMARENA, JORGE (BS)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:CAMARENA
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 S TRUMBULL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-4653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5341 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2817
Practice Address - Country:US
Practice Address - Phone:708-656-6430
Practice Address - Fax:708-656-6591
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1617631OtherBLUE CROSS BLUE SHIELD
IL202591OtherMEDICARE
IL362246705Medicaid