Provider Demographics
NPI:1811631880
Name:COSBY, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:COSBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-4338
Mailing Address - Country:US
Mailing Address - Phone:773-826-2929
Mailing Address - Fax:773-826-2964
Practice Address - Street 1:3408 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-4338
Practice Address - Country:US
Practice Address - Phone:773-826-2929
Practice Address - Fax:773-826-2964
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171M00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator