1104243658 NPI number — JESSICA LOFTUS, PH.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104243658 NPI number — JESSICA LOFTUS, PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JESSICA LOFTUS, PH.D.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104243658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7250 W COLLEGE DR
Provider Second Line Business Mailing Address:
#1W
Provider Business Mailing Address City Name:
PALOS HEIGHTS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60463-1151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7250 W COLLEGE DR
Provider Second Line Business Practice Location Address:
#1W
Provider Business Practice Location Address City Name:
PALOS HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60463-1151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-448-1306
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LOFTUS
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSED CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
708-448-1306

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  071-005326 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1622293 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 453170 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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