Provider Demographics
NPI:1184798753
Name:KUCKUCK, EVONNE M (LCPC, ATR)
Entity type:Individual
Prefix:MRS
First Name:EVONNE
Middle Name:M
Last Name:KUCKUCK
Suffix:
Gender:
Credentials:LCPC, ATR
Other - Prefix:MS
Other - First Name:EVONNE
Other - Middle Name:M
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC, ATR
Mailing Address - Street 1:534 COVENTRY RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-1743
Mailing Address - Country:US
Mailing Address - Phone:618-531-2435
Mailing Address - Fax:
Practice Address - Street 1:552 EDWARDSVILLE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-1338
Practice Address - Country:US
Practice Address - Phone:618-531-2435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-004352101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06032019OtherBCBS PPO
670554OtherHEALTHLINK HMO & PPO