Provider Demographics
NPI:1952177461
Name:RODRIGUEX WELLMAKER, JESSICA CATHERINE (LCPC, ASOP)
Entity Type:Individual
Prefix:
First Name:JESSICA CATHERINE
Middle Name:
Last Name:RODRIGUEX WELLMAKER
Suffix:
Gender:F
Credentials:LCPC, ASOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-3547
Mailing Address - Country:US
Mailing Address - Phone:408-656-0623
Mailing Address - Fax:
Practice Address - Street 1:1720 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2930
Practice Address - Country:US
Practice Address - Phone:408-656-0623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.015662101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional