Provider Demographics
NPI:1124177878
Name:MATLOCK, JANICE L (MFT)
Entity type:Individual
Prefix:DR
First Name:JANICE
Middle Name:L
Last Name:MATLOCK
Suffix:
Gender:
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 S FULMER ST
Mailing Address - Street 2:
Mailing Address - City:NAUVOO
Mailing Address - State:IL
Mailing Address - Zip Code:62354-1307
Mailing Address - Country:US
Mailing Address - Phone:217-453-6783
Mailing Address - Fax:217-453-6783
Practice Address - Street 1:45 S PARK BLVD
Practice Address - Street 2:STE 255
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6280
Practice Address - Country:US
Practice Address - Phone:630-942-8803
Practice Address - Fax:630-942-8845
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist