Provider Demographics
NPI:1902174329
Name:LEBRECK, JACQUELYN (LCPC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:
Last Name:LEBRECK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NORTHWEST HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:FOX RIVER GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60021
Mailing Address - Country:US
Mailing Address - Phone:847-370-4969
Mailing Address - Fax:
Practice Address - Street 1:110 NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:FOX RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60021-1017
Practice Address - Country:US
Practice Address - Phone:847-370-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-007954101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207844Medicare PIN
IL1633897OtherGROUP BCBS
IL1679546873OtherGROUP NPI NUMBER
IL32-0084889OtherTAX ID NUMBER