Provider Demographics
NPI:1720376221
Name:LAURSON, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:LAURSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 E WASHINGTON STREET
Mailing Address - Street 2:#A3
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704
Mailing Address - Country:US
Mailing Address - Phone:309-242-3975
Mailing Address - Fax:
Practice Address - Street 1:2416 E WASHINGTON STREET
Practice Address - Street 2:#A3
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704
Practice Address - Country:US
Practice Address - Phone:309-242-3975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006977101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor