Provider Demographics
NPI:1164300976
Name:MOSQUERA, JAX ANTHONY
Entity type:Individual
Prefix:
First Name:JAX
Middle Name:ANTHONY
Last Name:MOSQUERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5452 N ASHLAND AVE # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1101
Mailing Address - Country:US
Mailing Address - Phone:773-332-8891
Mailing Address - Fax:
Practice Address - Street 1:1740 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5918
Practice Address - Country:US
Practice Address - Phone:847-558-7327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health