Provider Demographics
NPI:1760885255
Name:JACQUE RUCH LCSW, LTD.
Entity Type:Organization
Organization Name:JACQUE RUCH LCSW, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUCH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:815-243-8332
Mailing Address - Street 1:4635 BEDFORDSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4481
Mailing Address - Country:US
Mailing Address - Phone:815-243-8332
Mailing Address - Fax:
Practice Address - Street 1:6975 REDANSA DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1201
Practice Address - Country:US
Practice Address - Phone:815-398-7000
Practice Address - Fax:815-395-0671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149015073251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1407129471OtherNPI
IL375792Medicare Oscar/Certification