Provider Demographics
NPI:1568635910
Name:PECKELS, JASON ANDREW (MSED, LPC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ANDREW
Last Name:PECKELS
Suffix:
Gender:M
Credentials:MSED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 BURRMONT RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1842
Mailing Address - Country:US
Mailing Address - Phone:414-801-7905
Mailing Address - Fax:
Practice Address - Street 1:433 PHELPS AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2442
Practice Address - Country:US
Practice Address - Phone:815-397-4287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005895101YP2500X
WI3938-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional