Provider Demographics
NPI:1225855687
Name:GEBHARDT, JAMIE MARASCO
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:MARASCO
Last Name:GEBHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 N MILWAUKEE AVE APT 406
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-4299
Mailing Address - Country:US
Mailing Address - Phone:414-801-1255
Mailing Address - Fax:
Practice Address - Street 1:6430 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-2925
Practice Address - Country:US
Practice Address - Phone:312-806-7937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-378357106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician