Provider Demographics
NPI:1316315716
Name:JACQUELYN A MUNIZ, PSY.D., LLC
Entity type:Organization
Organization Name:JACQUELYN A MUNIZ, PSY.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUNIZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:618-964-4255
Mailing Address - Street 1:11264 ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-8360
Mailing Address - Country:US
Mailing Address - Phone:618-964-4255
Mailing Address - Fax:189-997-7972
Practice Address - Street 1:11264 ROUTE 37
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-8360
Practice Address - Country:US
Practice Address - Phone:618-964-4255
Practice Address - Fax:618-997-7972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-02
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005891103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty