Provider Demographics
NPI:1376660696
Name:MCDOUGAL, JACQUELINE D (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:D
Last Name:MCDOUGAL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 TOWER HILL LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-3060
Mailing Address - Country:US
Mailing Address - Phone:248-652-6044
Mailing Address - Fax:
Practice Address - Street 1:2516 TOWER HILL LN
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48306-3060
Practice Address - Country:US
Practice Address - Phone:248-652-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008138103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301008138OtherBOARD -PSYCHOLOGY LICENSE