Provider Demographics
NPI:1538738430
Name:JONES, KAITLIN COSTELLO (MSW, LSW)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:COSTELLO
Last Name:JONES
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 BASSWOOD LN
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5749
Mailing Address - Country:US
Mailing Address - Phone:217-274-8953
Mailing Address - Fax:
Practice Address - Street 1:207 E HAMILTON RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7527
Practice Address - Country:US
Practice Address - Phone:217-274-8953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.101368104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker