Healthcare Provider Details

I. General information

NPI: 1982080214
Provider Name (Legal Business Name): JAMIE MIROCHA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24012 W RENWICK RD STE 204A
PLAINFIELD IL
60544-8733
US

IV. Provider business mailing address

24012 W RENWICK RD STE 204A
PLAINFIELD IL
60544-8733
US

V. Phone/Fax

Practice location:
  • Phone: 815-676-4688
  • Fax: 815-676-4498
Mailing address:
  • Phone: 815-676-4688
  • Fax: 815-676-4498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149017464
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: