Provider Demographics
NPI:1003307240
Name:RALPH, JACQUELYN (PPC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:RALPH
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 N 4TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2091
Mailing Address - Country:US
Mailing Address - Phone:307-721-0700
Mailing Address - Fax:
Practice Address - Street 1:1575 N 4TH ST STE 103
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2091
Practice Address - Country:US
Practice Address - Phone:307-721-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2021-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1254101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health