Provider Demographics
NPI:1003919408
Name:PICKAR-MUNIZ, JACQUELYN ANN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:ANN
Last Name:PICKAR-MUNIZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:ANN
Other - Last Name:PICKAR MUNIZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:315 S 13TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3661
Mailing Address - Country:US
Mailing Address - Phone:618-964-4255
Mailing Address - Fax:618-942-5921
Practice Address - Street 1:315 S 13TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3661
Practice Address - Country:US
Practice Address - Phone:618-964-4255
Practice Address - Fax:618-942-5921
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005891103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
10032028OtherBCBS
IL209110Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
S08909Medicare UPIN
K06934Medicare ID - Type Unspecified