Provider Demographics
NPI:1770927626
Name:CARSON, JACQUELYN HERNANDEZ (MSMFT)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:HERNANDEZ
Last Name:CARSON
Suffix:
Gender:F
Credentials:MSMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3235
Mailing Address - Country:US
Mailing Address - Phone:847-219-2842
Mailing Address - Fax:
Practice Address - Street 1:316 WESLEY AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3235
Practice Address - Country:US
Practice Address - Phone:847-219-2842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist