Provider Demographics
NPI:1841648136
Name:WILLIAMS, JACQUELINE LARAE (LPC)
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:LARAE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 S WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2825
Mailing Address - Country:US
Mailing Address - Phone:312-808-3210
Mailing Address - Fax:
Practice Address - Street 1:40 E 9TH ST APT 1907
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-2136
Practice Address - Country:US
Practice Address - Phone:312-217-0503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178-002148101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional