Provider Demographics
NPI:1457752719
Name:KOVACEVIC, MERDIJANA (BS)
Entity Type:Individual
Prefix:
First Name:MERDIJANA
Middle Name:
Last Name:KOVACEVIC
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 W JACKSON BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2847
Mailing Address - Country:US
Mailing Address - Phone:312-942-8387
Mailing Address - Fax:
Practice Address - Street 1:1645 W JACKSON BLVD STE 602
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2847
Practice Address - Country:US
Practice Address - Phone:312-942-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL071.010664103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program