Provider Demographics
NPI:1023179611
Name:LINDO, JACQUELINE GRISELLE (MS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GRISELLE
Last Name:LINDO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10045 W LISBON AVE STE 221
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2446
Mailing Address - Country:US
Mailing Address - Phone:414-358-7144
Mailing Address - Fax:414-358-7158
Practice Address - Street 1:10045 W LISBON AVE STE 221
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2446
Practice Address - Country:US
Practice Address - Phone:414-358-7144
Practice Address - Fax:414-358-7158
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
221700000X
WI611-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist