Active NPI
Jane Ellen Samuelson, PH. D.
- Clinical Psychologist
- Chicago, IL
National Provider Identifier
1346468394
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- Practice address
- 111 N Wabash Ave
Suite 1704
Chicago, IL 60602-1903 - Phone
- (708) 524-1267
- NPI assigned
- Apr 23, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | IL | Primary |
Addresses
Primary practice location
111 N Wabash Ave
Suite 1704
Chicago, IL 60602-1903
Mailing address
208 S Maple Ave
Apt. 19
Oak Park, IL 60302-3028
Phone (708) 524-1267
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective May 19, 2022 through May 19, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 071003172 | IL | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1177286400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1346468394",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "208 S MAPLE AVE",
"address_2": "APT. 19",
"city": "OAK PARK",
"state": "IL",
"postal_code": "603023028",
"telephone_number": "708-524-1267"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "111 N WABASH AVE",
"address_2": "SUITE 1704",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606021903",
"telephone_number": "708-524-1267"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SAMUELSON",
"first_name": "JANE",
"middle_name": "ELLEN",
"name_prefix": "Dr.",
"credential": "PH. D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-04-23",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "IL",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.