Provider Demographics
NPI:1225021728
Name:PEPPER, JACQUELINE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:PEPPER
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 1:1007 N COLLEGE AVE
Mailing Address - Street 2:ST. 1
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-4794
Mailing Address - Country:US
Mailing Address - Phone:573-214-2253
Mailing Address - Fax:573-474-5683
Practice Address - Street 1:1007 N COLLEGE AVE
Practice Address - Street 2:ST. 1
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-4794
Practice Address - Country:US
Practice Address - Phone:573-214-2253
Practice Address - Fax:573-474-5683
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW0052461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498301332Medicaid
MO753424407Medicaid
MO24647036OtherBC/BS PROVIDER NUMBER
MOB04C640Medicare ID - Type UnspecifiedPROVIDER NUMBER