Provider Demographics
NPI:1326333535
Name:CONQUEST, JACQUELINE MARIE (MA, LMHC, CCH)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:CONQUEST
Suffix:
Gender:F
Credentials:MA, LMHC, CCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16520 72ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028
Mailing Address - Country:US
Mailing Address - Phone:206-330-6497
Mailing Address - Fax:
Practice Address - Street 1:21907 64TH AVE W STE 220
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-6200
Practice Address - Country:US
Practice Address - Phone:206-330-6497
Practice Address - Fax:425-640-9600
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 00006954101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health