Individual
JACQUELINE LISSETTE VACA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPC
Contact information
Practice address
1432 N HAMLIN AVE, CHICAGO, IL 60651-2142
(773) 805-6738
Mailing address
5100 N RAVENSWOOD AVE, SUITE 245, CHICAGO, IL 60640-2713
(773) 769-0205
(773) 765-0794
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
178.006285
IL
101YP2500X
Professional Counselor
Primary
180.008127
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1616824
BLUE CROSS BLUE SHIELD
IL
Enumeration date
07/12/2011
Last updated
12/10/2014
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