Doctor Name: | SANDRA JACQUES |
NPI Number: | 1154312544 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LCSW |
License Number: | 548123 |
Business Practice Address: | 121 W Main St Suite 350 Port Washington, WI - 530741813 |
Business Phone Number: | 2622848130 |
Business Fax Number: | 2622848104 |
Mailing Address: | Po Box 994, Suite 350 PORT WASHINGTON |
State: | WI |
Postal Code: | 530740994 |
Phone Number: | 2622848130 |
Fax Number: | 2622848104 |
NPI Enumeration Date: | 11/03/2005 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 1041C0700X |
License Number: | 548123 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WI |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Social Worker |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: | A social worker who holds a master |