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General NPI Number Information
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NPI Number | 1316315716
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Entity Type | Organization
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Legal Business Name | JACQUELYN A MUNIZ, PSY.D., LLC
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Dates
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Enumeration Date | 09/02/2015
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Last Update Date | 08/27/2024
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Provider Practice Location Address
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Address Line | 11264 ROUTE 37
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City | MARION
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State | IL
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Zip | 62959-8360
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Country | US
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Telephone | 618-964-4255
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Fax | 618-997-7972
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Provider Business Mailing Address
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Address Line | 11264 ROUTE 37
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City | MARION
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State | IL
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Zip | 62959-8360
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Country | US
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Telephone | 618-964-4255
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Fax | 189-997-7972
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | JACQUELYN A MUNIZ
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Credential | PSY.D.
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Telephone | 618-964-4255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 071005891
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License Number State | IL
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