Basic Information
| Provider Information | |||||||||
| NPI: | 1306194923 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RELLE | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | LPC, AMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 N MULFORD RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611073877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153875600 | ||||||||
| FaxNumber: | 8153915041 | ||||||||
| Practice Location | |||||||||
| Address1: | 8616 NORTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611075309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153388003 | ||||||||
| FaxNumber: | 8153326090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 178.008877 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | 208.000240 | IL | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.