Provider Demographics
NPI:1932743663
Name:LORD, JERIDITH ANN (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:JERIDITH
Middle Name:ANN
Last Name:LORD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 37, BOX 3086
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09459
Mailing Address - Country:US
Mailing Address - Phone:516-308-6951
Mailing Address - Fax:
Practice Address - Street 1:226 W JUDD ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3158
Practice Address - Country:US
Practice Address - Phone:815-575-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.013771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health