=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760085328
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE WROBLEWSKI LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2020
-----------------------------------------------------
Last Update Date | 04/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1518 PEORIA ST
-----------------------------------------------------
City | PERU
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61354-2214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-200-9635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1609 10TH ST
-----------------------------------------------------
City | PERU
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61354-2239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180.013155
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------