Provider Demographics
NPI:1124273149
Name:KLINKNER, JEROME J (LCSW)
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:J
Last Name:KLINKNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 RIDGE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-6416
Mailing Address - Country:US
Mailing Address - Phone:847-866-9067
Mailing Address - Fax:
Practice Address - Street 1:6450 N RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-4804
Practice Address - Country:US
Practice Address - Phone:773-743-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0078381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK20147OtherMEDICARE, PROVIDER ID, PROVIDER IN A GROUP