Healthcare Provider Details

I. General information

NPI: 1619286986
Provider Name (Legal Business Name): JACQUELYN EILEEN AUGUSTINE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 BOND ST STE 127
NAPERVILLE IL
60563-2769
US

IV. Provider business mailing address

1415 BOND ST
NAPERVILLE IL
60563-2388
US

V. Phone/Fax

Practice location:
  • Phone: 630-355-9002
  • Fax:
Mailing address:
  • Phone: 630-355-9002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008317
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: