Provider Demographics
NPI:1578215414
Name:JANCOLA, ANGELA E (LCSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:E
Last Name:JANCOLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 LAKE PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7132
Mailing Address - Country:US
Mailing Address - Phone:217-493-6193
Mailing Address - Fax:
Practice Address - Street 1:411 E PARK ST STE 106
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3862
Practice Address - Country:US
Practice Address - Phone:217-714-7042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.022802101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health