Basic Information
| Provider Information | |||||||||
| NPI: | 1144573205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAIG | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2615 EDWARDS ST | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620023915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184622331 | ||||||||
| FaxNumber: | 6182082271 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 EDWARDS ST | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620023915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184622331 | ||||||||
| FaxNumber: | 6182082271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2012 | ||||||||
| LastUpdateDate: | 10/25/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 180002269 | IL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 180002269 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.