Provider Demographics
NPI:1588738652
Name:SANDERS, JACK CHARLES (MSW)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:CHARLES
Last Name:SANDERS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2229 WEST FARWELL AVE
Mailing Address - Street 2:1 WEST
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-4809
Mailing Address - Country:US
Mailing Address - Phone:773-467-1154
Mailing Address - Fax:773-262-7237
Practice Address - Street 1:6650 NORTH NORTHWEST HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1307
Practice Address - Country:US
Practice Address - Phone:773-467-1154
Practice Address - Fax:773-262-7237
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633967OtherBLUE CROSS BLUE SHIELD IL
IL01633967OtherBLUE CROSS BLUE SHIELD IL