Healthcare Provider Details

I. General information

NPI: 1104758721
Provider Name (Legal Business Name): MAYRA GUADALUPE JARAMILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6321 N AVONDALE AVE
CHICAGO IL
60631-1900
US

IV. Provider business mailing address

414 NORTHSHORE DR
MUNDELEIN IL
60060-2620
US

V. Phone/Fax

Practice location:
  • Phone: 773-774-4444
  • Fax:
Mailing address:
  • Phone: 872-226-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: