Provider Demographics
NPI:1033624044
Name:WATKINS, JACQUELINE (SOCIAL WORK LMSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WATKINS
Suffix:
Gender:F
Credentials:SOCIAL WORK LMSW
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1341 BERTRAM ST
Mailing Address - Street 2:
Mailing Address - City:BERTRAM
Mailing Address - State:IA
Mailing Address - Zip Code:52403-9001
Mailing Address - Country:US
Mailing Address - Phone:319-866-6000
Mailing Address - Fax:
Practice Address - Street 1:1341 BERTRAM ST
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-9001
Practice Address - Country:US
Practice Address - Phone:319-866-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0864661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA086466Medicaid