Healthcare Provider Details

I. General information

NPI: 1518022649
Provider Name (Legal Business Name): TRACY ANN STUCKER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W WALNUT ST STE 1
JACKSONVILLE IL
62650-1159
US

IV. Provider business mailing address

1515 W WALNUT ST STE 1
JACKSONVILLE IL
62650-1159
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-7275
  • Fax: 217-245-7427
Mailing address:
  • Phone: 217-245-7275
  • Fax: 217-245-7427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149-012226
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: