Provider Demographics
NPI:1154312544
Name:JACQUES, SANDRA (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
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:PO BOX 994
Mailing Address - Street 2:SUITE 350
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-0994
Mailing Address - Country:US
Mailing Address - Phone:262-284-8130
Mailing Address - Fax:262-284-8104
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:SUITE 350
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1813
Practice Address - Country:US
Practice Address - Phone:262-284-8130
Practice Address - Fax:262-284-8104
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5481231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39246300Medicaid