Provider Demographics
NPI:1265236285
Name:MIRZA, JADIS SD
Entity type:Individual
Prefix:
First Name:JADIS
Middle Name:SD
Last Name:MIRZA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:JADIS
Other - Middle Name:
Other - Last Name:BRAVEHEART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3012 W WARREN BLVD APT 1R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1844
Mailing Address - Country:US
Mailing Address - Phone:847-255-9757
Mailing Address - Fax:
Practice Address - Street 1:3012 W WARREN BLVD APT 1R
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1844
Practice Address - Country:US
Practice Address - Phone:847-255-9757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No1744R1102XOther Service ProvidersSpecialistResearch Study