Provider Demographics
NPI:1003919408
Name:MUNIZ, JACQUELYN A (PSYD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:A
Last Name:MUNIZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:A
Other - Last Name:PICKAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:11264 ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-8360
Mailing Address - Country:US
Mailing Address - Phone:618-964-4255
Mailing Address - Fax:618-997-7972
Practice Address - Street 1:11264 ROUTE 37
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-8360
Practice Address - Country:US
Practice Address - Phone:618-964-4255
Practice Address - Fax:618-997-7972
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005891103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
10032028OtherBCBS
IL209110Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
S08909Medicare UPIN
K06934Medicare ID - Type Unspecified