Provider Demographics
NPI:1316112147
Name:ALDRIDGE, JACLYN ELAINE (MSW, LSW)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:ELAINE
Last Name:ALDRIDGE
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:MISS
Other - First Name:JACLYN
Other - Middle Name:ELAINE
Other - Last Name:DANOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:604 W JOHN ST
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-5812
Mailing Address - Country:US
Mailing Address - Phone:217-840-8319
Mailing Address - Fax:
Practice Address - Street 1:1109 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-4703
Practice Address - Country:US
Practice Address - Phone:217-333-2705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.011456104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker