Provider Demographics
NPI:1326193921
Name:WHITEHEAD, JACQUELINE T (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:T
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JACQUELINE
Other - Middle Name:TEDESCO
Other - Last Name:WHITEHEAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:43 EAGLE HOLLOW DR.
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-559-3904
Mailing Address - Fax:
Practice Address - Street 1:43 EAGLE HOLLOW DR.
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-559-3904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT0042431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical