Healthcare Provider Details

I. General information

NPI: 1023449972
Provider Name (Legal Business Name): JENNIE N. MARQUEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2013
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4777 E STATE ST SUITE 1
ROCKFORD IL
61108-2273
US

IV. Provider business mailing address

416 E LINCOLN AVE
BELVIDERE IL
61008-2839
US

V. Phone/Fax

Practice location:
  • Phone: 815-977-1425
  • Fax:
Mailing address:
  • Phone: 815-977-1425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180-006644
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.008535
License Number StateIL

VIII. Authorized Official

Name: MRS. JENNIE N. MARQUEZ
Title or Position: CEO
Credential: LCPC
Phone: 815-977-1425