Provider Demographics
NPI:1447827522
Name:ROSE, JAKOB (LCSW)
Entity type:Individual
Prefix:
First Name:JAKOB
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3727 N PINE GROVE AVE APT 212
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4183
Mailing Address - Country:US
Mailing Address - Phone:913-972-8273
Mailing Address - Fax:
Practice Address - Street 1:650 N DEARBORN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3873
Practice Address - Country:US
Practice Address - Phone:331-251-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490232571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical