Provider Demographics
NPI:1619476793
Name:JURICH, A'NNA (LCPC)
Entity Type:Individual
Prefix:
First Name:A'NNA
Middle Name:
Last Name:JURICH
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 1:1080 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3812
Mailing Address - Country:US
Mailing Address - Phone:618-529-1151
Mailing Address - Fax:
Practice Address - Street 1:8474 MARTIN ST
Practice Address - Street 2:
Practice Address - City:CHRISTOPHER
Practice Address - State:IL
Practice Address - Zip Code:62822-2354
Practice Address - Country:US
Practice Address - Phone:618-218-3394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-004996101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL000Medicaid