Healthcare Provider Details

I. General information

NPI: 1083754931
Provider Name (Legal Business Name): JENNIFER MARIE THOMASON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER MARIE HARTRY LCPC

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 03/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S 4TH ST
OREGON IL
61061-1609
US

IV. Provider business mailing address

5259 S MILL POND RD
ROCHELLE IL
61068-9136
US

V. Phone/Fax

Practice location:
  • Phone: 815-732-3157
  • Fax: 815-732-3834
Mailing address:
  • Phone: 815-562-9509
  • 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: