Provider Demographics
NPI:1801003462
Name:JAY, MICHAEL R (LCPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:JAY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 W EXCHANGE ST
Mailing Address - Street 2:PO BOX 813
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4030
Mailing Address - Country:US
Mailing Address - Phone:815-599-7372
Mailing Address - Fax:
Practice Address - Street 1:421 W EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4030
Practice Address - Country:US
Practice Address - Phone:815-599-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1800061921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical