Provider Demographics
NPI:1346902632
Name:JAMIE LAURSON LCPC PLLC
Entity type:Organization
Organization Name:JAMIE LAURSON LCPC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-242-3975
Mailing Address - Street 1:2416 E WASHINGTON ST STE A3
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1608
Mailing Address - Country:US
Mailing Address - Phone:309-242-3975
Mailing Address - Fax:
Practice Address - Street 1:2416 E WASHINGTON ST STE A3
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-1608
Practice Address - Country:US
Practice Address - Phone:309-242-3975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-13
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty