Provider Demographics
NPI:1639594971
Name:PANCHAL, JAYSHREE (MA, LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:JAYSHREE
Middle Name:
Last Name:PANCHAL
Suffix:
Gender:F
Credentials:MA, LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 N VILLA LAKE DR STE C
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8290
Mailing Address - Country:US
Mailing Address - Phone:309-713-1485
Mailing Address - Fax:309-419-4328
Practice Address - Street 1:7210 N VILLA LAKE DR STE C
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-8290
Practice Address - Country:US
Practice Address - Phone:309-713-1485
Practice Address - Fax:309-419-4328
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010474101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional