Provider Demographics
NPI:1952594442
Name:MORAN, JEREMIAH P SR (MSW LCSW)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:P
Last Name:MORAN
Suffix:SR
Gender:M
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 N KEDVALE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630
Mailing Address - Country:US
Mailing Address - Phone:773-545-0372
Mailing Address - Fax:
Practice Address - Street 1:4824 N KEDVALE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630
Practice Address - Country:US
Practice Address - Phone:773-545-0372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
929880Medicare UPIN