Individual
MRS. JACQUELYN A MITRA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCPC
Contact information
Practice address
405 KAYS DR, SUITE B, NORMAL, IL 61761-1979
(309) 862-0064
(309) 862-1542
Mailing address
405 KAYS DR, SUITE B, NORMAL, IL 61761-1979
(309) 862-0064
(309) 862-1542
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
180 006966
IL
Other
Enumeration date
11/07/2008
Last updated
02/01/2010
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