Provider Demographics
NPI:1093012684
Name:JENNINGS-MITCHELL, LAURA (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JENNINGS-MITCHELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E LINCOLN ST
Mailing Address - Street 2:STE 303
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6406
Mailing Address - Country:US
Mailing Address - Phone:309-451-9495
Mailing Address - Fax:
Practice Address - Street 1:705 E LINCOLN ST
Practice Address - Street 2:STE 303
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6406
Practice Address - Country:US
Practice Address - Phone:309-451-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490115661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical