Provider Demographics
NPI:1053899385
Name:ROMAN, JORGE LUIS
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:ROMAN
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 1:3220 LOMBARD AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3517
Mailing Address - Country:US
Mailing Address - Phone:773-574-8626
Mailing Address - Fax:
Practice Address - Street 1:3100 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-3956
Practice Address - Country:US
Practice Address - Phone:708-863-3803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst