Provider Demographics
NPI:1902935885
Name:NUSSBAUM, JAN H (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:H
Last Name:NUSSBAUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N MCCLURG CT
Mailing Address - Street 2:SUITE 3803
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3044
Mailing Address - Country:US
Mailing Address - Phone:312-642-4772
Mailing Address - Fax:312-266-6375
Practice Address - Street 1:600 N MCCLURG CT
Practice Address - Street 2:SUITE 3803
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3044
Practice Address - Country:US
Practice Address - Phone:312-642-4772
Practice Address - Fax:312-266-6375
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical