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General NPI Number Information
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NPI Number | 1659620458
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Entity Type | Individual
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Provider Name | JESSICA MICHELLE BULTHOUSE M.S., LCPC
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Gender | Female
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Dates
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Enumeration Date | 09/07/2012
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Last Update Date | 05/18/2015
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Provider Practice Location Address
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Address Line | 304 8TH ST
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City | CHARLESTON
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State | IL
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Zip | 61920-1504
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Country | US
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Telephone | 217-508-7415
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Fax |
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Provider Business Mailing Address
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Address Line | 311 W MAIN ST
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City | OAKLAND
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State | IL
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Zip | 61943-7109
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Country | US
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Telephone | 217-508-7415
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 178.008309
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180009706
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License Number State | IL
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