Healthcare Provider Details

I. General information

NPI: 1740468941
Provider Name (Legal Business Name): ANDA JINES MS, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDA ERCUM-KRASINSKI MS

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16325 HARLEM AVE SUITE 200
TINLEY PARK IL
60477-2509
US

IV. Provider business mailing address

ESPERANZA FAMILY HEALTH CENTER 903 C 5TH ST.
ESTANCIA NM
87016
US

V. Phone/Fax

Practice location:
  • Phone: 708-429-6999
  • Fax: 708-429-6909
Mailing address:
  • Phone: 505-384-2777
  • Fax: 505-384-2204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.006911
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0182711
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: