Provider Demographics
NPI:1861603052
Name:WATSON, EASTER JEAN
Entity type:Individual
Prefix:
First Name:EASTER
Middle Name:JEAN
Last Name:WATSON
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 1:8049 S SACRAMENTO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-2732
Mailing Address - Country:US
Mailing Address - Phone:773-306-1570
Mailing Address - Fax:773-306-1571
Practice Address - Street 1:8049 S SACRAMENTO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-2732
Practice Address - Country:US
Practice Address - Phone:773-306-1570
Practice Address - Fax:773-306-1571
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-27
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
IL17965OtherMISA II
IL17965OtherCMADC
ILICCSO1140OtherCCS
IL22134OtherCCJP
ILEW44070604POtherEARLY INTERVENTION SPEC.
IL21722OtherPCGC