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General NPI Number Information
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NPI Number | 1265970180
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Entity Type | Organization
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Legal Business Name | JACQUE RUCH LCSW, LTD.
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Dates
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Enumeration Date | 02/11/2017
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Last Update Date | 02/11/2017
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Provider Practice Location Address
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Address Line | 650 N MAIN ST
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City | ROCKFORD
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State | IL
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Zip | 61103-6921
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Country | US
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Telephone | 815-243-8332
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Fax | 847-693-3099
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Provider Business Mailing Address
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Address Line | 650 N MAIN ST
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City | ROCKFORD
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State | IL
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Zip | 61103-6921
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Country | US
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Telephone | 815-243-8332
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Fax | 847-693-3099
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MISSY L WILSON
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Credential |
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Telephone | 815-621-1932
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number | 149015073
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License Number State | IL
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