Provider Demographics
NPI:1407055528
Name:MAXAM, JACQUELINE NICOLE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:MAXAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:NICOLE
Other - Last Name:FRENCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1520 N MEADE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3762
Mailing Address - Country:US
Mailing Address - Phone:920-734-7181
Mailing Address - Fax:920-734-0621
Practice Address - Street 1:1520 N MEADE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3762
Practice Address - Country:US
Practice Address - Phone:920-734-7181
Practice Address - Fax:920-734-0621
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI471-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41150900Medicaid