Provider Demographics
NPI:1003804451
Name:ST. GERMAINE, JACQUELYN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:ST. GERMAINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 E. FORT LOWELL ROAD
Mailing Address - Street 2:#122
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705
Mailing Address - Country:US
Mailing Address - Phone:520-325-6097
Mailing Address - Fax:520-531-1095
Practice Address - Street 1:380 E FORT LOWELL RD
Practice Address - Street 2:#122
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-3985
Practice Address - Country:US
Practice Address - Phone:520-325-6097
Practice Address - Fax:520-531-1095
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3017103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPHD3017Medicare ID - Type UnspecifiedMEDICARE NUMBER