Basic Information
| Provider Information | |||||||||
| NPI: | 1982698833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMPINE | ||||||||
| FirstName: | JON-PAUL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 316 MAIN ST | ||||||||
| Address2: | UNIT 3 | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602024538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475714985 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2530 CRAWFORD AVE | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602014970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478694650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.