Provider Demographics
NPI:1376286922
Name:WHITING, JACQUELINE NICOLE (MS LASAC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:WHITING
Suffix:
Gender:F
Credentials:MS LASAC
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:COGHILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS LASAC
Mailing Address - Street 1:PO BOX 90795
Mailing Address - Street 2:
Mailing Address - City:WHITE MOUNTAIN LAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85912-0795
Mailing Address - Country:US
Mailing Address - Phone:928-228-6910
Mailing Address - Fax:
Practice Address - Street 1:500 W OLD LINDEN RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-4608
Practice Address - Country:US
Practice Address - Phone:928-537-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ917725101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool