Healthcare Provider Details

I. General information

NPI: 1467366617
Provider Name (Legal Business Name): JENNIFER CONNELLY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W SPRINGFIELD AVE STE 210
CHAMPAIGN IL
61820-4877
US

IV. Provider business mailing address

201 W SPRINGFIELD AVE STE 210
CHAMPAIGN IL
61820-4877
US

V. Phone/Fax

Practice location:
  • Phone: 217-403-3352
  • Fax: 217-403-3353
Mailing address:
  • Phone: 217-403-3352
  • Fax: 217-403-3353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178033571
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: