Provider Demographics
NPI:1275560278
Name:HOSTETLER, JACQUELYN S (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:S
Last Name:HOSTETLER
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 1:416 W. REED ST.
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270
Mailing Address - Country:US
Mailing Address - Phone:660-263-7651
Mailing Address - Fax:660-263-2815
Practice Address - Street 1:416 W REED ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-1516
Practice Address - Country:US
Practice Address - Phone:660-263-7651
Practice Address - Fax:660-263-2815
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060078211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical