MEDICARE: JACLYN M ANTONIOLLI LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	178017239	IL

General Provider Information

NPI Number	:	1548936958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN M ANTONIOLLI LPC

Provider Business Mailing Address
First Line	:	7330 W COLLEGE DR STE 206
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1157
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7330 W COLLEGE DR STE 206
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1157
Country	:	US
Telephone Number	:	224-424-3105
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2021
Last Update Date	:	08/17/2021

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