Healthcare Provider Details

I. General information

NPI: 1912849704
Provider Name (Legal Business Name): JAKE CARMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4481 ASH GROVE DR STE B
SPRINGFIELD IL
62711-6359
US

IV. Provider business mailing address

728 W WOODLAND AVE
SPRINGFIELD IL
62704-2837
US

V. Phone/Fax

Practice location:
  • Phone: 847-809-2669
  • Fax:
Mailing address:
  • Phone: 847-809-2669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberNCC2527016
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: