Provider Demographics
NPI:1407042146
Name:CLANCE, JACQUELINE CAUPRICE (MS, LPC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:CAUPRICE
Last Name:CLANCE
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 FIELDWOOD DR NW
Mailing Address - Street 2:
Mailing Address - City:ADAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30103-5369
Mailing Address - Country:US
Mailing Address - Phone:706-263-8252
Mailing Address - Fax:
Practice Address - Street 1:549 FIELDWOOD DR NW
Practice Address - Street 2:
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103-5369
Practice Address - Country:US
Practice Address - Phone:706-263-8252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006562101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional