Provider Demographics
NPI:1225545734
Name:JARVIS-ANDERSON, BERNICE E (CADC, LPC)
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:E
Last Name:JARVIS-ANDERSON
Suffix:
Gender:F
Credentials:CADC, LPC
Other - Prefix:
Other - First Name:BERNICE
Other - Middle Name:E
Other - Last Name:JARVIS-ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BERNICE E ANDERSON
Mailing Address - Street 1:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-7109
Mailing Address - Country:US
Mailing Address - Phone:815-756-4875
Mailing Address - Fax:
Practice Address - Street 1:12 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9637
Practice Address - Country:US
Practice Address - Phone:815-756-4875
Practice Address - Fax:815-756-2944
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.013543101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL474579189001Medicaid