Provider Demographics
NPI:1134323116
Name:JACQUES, JENNIFER MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:JACQUES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 ROOSA GAP RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12721-5124
Mailing Address - Country:US
Mailing Address - Phone:718-652-0227
Mailing Address - Fax:
Practice Address - Street 1:531 ROOSA GAP RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGBURG
Practice Address - State:NY
Practice Address - Zip Code:12721-5124
Practice Address - Country:US
Practice Address - Phone:718-652-0227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0704321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical