Healthcare Provider Details

I. General information

NPI: 1699781260
Provider Name (Legal Business Name): JANE VELEZ PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 N FAIRMONT DRIVE
PEORIA IL
61614
US

IV. Provider business mailing address

5505 N FAIRMONT DR
PEORIA IL
61614-4246
US

V. Phone/Fax

Practice location:
  • Phone: 309-689-6700
  • Fax: 309-689-0774
Mailing address:
  • Phone: 309-689-6700
  • Fax: 309-689-0774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-005320
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: