Provider Demographics
NPI:1104247709
Name:MIKULECKY, JESSICA (PSYD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:MIKULECKY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 S 75TH AVE
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1033
Mailing Address - Country:US
Mailing Address - Phone:708-671-8440
Mailing Address - Fax:708-671-8446
Practice Address - Street 1:11800 S 75TH AVE
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1033
Practice Address - Country:US
Practice Address - Phone:708-671-8440
Practice Address - Fax:708-671-8446
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.009650101YP2500X
IL071009204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional