Provider Demographics
NPI:1013535236
Name:CHARLES, JACQUELINE ELIZABETH (LPC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELIZABETH
Last Name:CHARLES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 QUALITY AVE S
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MN
Mailing Address - Zip Code:55043-9656
Mailing Address - Country:US
Mailing Address - Phone:307-575-5257
Mailing Address - Fax:
Practice Address - Street 1:215 N 2ND ST STE 109
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-3707
Practice Address - Country:US
Practice Address - Phone:715-629-7047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7581-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional