Basic Information
Provider Information | |||||||||
NPI: | 1265513097 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRUNK | ||||||||
FirstName: | JACLYN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 31480 N US HIGHWAY 45 | ||||||||
Address2: |   | ||||||||
City: | LIBERTYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 600489444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476802715 | ||||||||
FaxNumber: | 8476803832 | ||||||||
Practice Location | |||||||||
Address1: | 31480 N US HIGHWAY 45 | ||||||||
Address2: |   | ||||||||
City: | LIBERTYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 60048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476802715 | ||||||||
FaxNumber: | 4768038328 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2006 | ||||||||
LastUpdateDate: | 08/10/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149010467 | IL | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | JB72430604P | 01 | IL | EARLY INTERVENTION | OTHER |