Provider Demographics
NPI:1982733531
Name:JARCZOK, SUSANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:
Last Name:JARCZOK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 CUYLER AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1423
Mailing Address - Country:US
Mailing Address - Phone:708-484-4180
Mailing Address - Fax:
Practice Address - Street 1:10001 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:IL
Practice Address - Zip Code:60131-2563
Practice Address - Country:US
Practice Address - Phone:847-451-0330
Practice Address - Fax:847-451-1652
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490096021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362235147Medicaid
IL201816Medicare ID - Type UnspecifiedINDIVIDUAL LEGACY #