MEDICARE: JOURNEY PROFESSIONAL COUNSELING LLC

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

General Provider Information

NPI Number	:	1770096174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOURNEY PROFESSIONAL COUNSELING LLC

Provider Business Mailing Address
First Line	:	304 8TH ST
Second Line	:
City	:	CHARLESTON
State	:	IL
Zip	:	61920-1504
Country	:	US
Telephone Number	:	217-345-4642
Fax Number	:

Provider Business Practice Location Address
First Line	:	304 8TH ST
Second Line	:
City	:	CHARLESTON
State	:	IL
Zip	:	61920-1504
Country	:	US
Telephone Number	:	217-345-4642
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	JESSICA BULTHOUSE
Credential	:
Telephone Number	:	217-508-7415

Provider Enumeration Date	:	11/08/2017
Last Update Date	:	11/08/2017

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