Provider Demographics
NPI:1619121373
Name:MITRA, JACQUELYN A (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:A
Last Name:MITRA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 KAYS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1979
Mailing Address - Country:US
Mailing Address - Phone:309-862-0064
Mailing Address - Fax:309-862-1542
Practice Address - Street 1:405 KAYS DR
Practice Address - Street 2:SUITE B
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1979
Practice Address - Country:US
Practice Address - Phone:309-862-0064
Practice Address - Fax:309-862-1542
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180 006966101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL588330Medicare PIN