Healthcare Provider Details

I. General information

NPI: 1487942454
Provider Name (Legal Business Name): JACQUELINE LISSETTE VACA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 N HAMLIN AVE
CHICAGO IL
60651-2142
US

IV. Provider business mailing address

5100 N RAVENSWOOD AVE SUITE 245
CHICAGO IL
60640-2713
US

V. Phone/Fax

Practice location:
  • Phone: 773-805-6738
  • Fax:
Mailing address:
  • Phone: 773-769-0205
  • Fax: 773-765-0794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.006285
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.008127
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: