Provider Demographics
NPI:1023630357
Name:BUSH, JANICE (LPC)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:JANICE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:909 W OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4962
Mailing Address - Country:US
Mailing Address - Phone:309-310-2856
Mailing Address - Fax:
Practice Address - Street 1:909 W OLIVE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4962
Practice Address - Country:US
Practice Address - Phone:309-310-2856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011545101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor