Provider Demographics
NPI:1407391295
Name:PRIDEMORE, JACQULINE NICOLE (MA, LPCC-S)
Entity Type:Individual
Prefix:
First Name:JACQULINE
Middle Name:NICOLE
Last Name:PRIDEMORE
Suffix:
Gender:F
Credentials:MA, LPCC-S
Other - Prefix:
Other - First Name:JACQULINE
Other - Middle Name:NICOLE
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPCC-S
Mailing Address - Street 1:4629 AICHOLTZ RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45244-1551
Mailing Address - Country:US
Mailing Address - Phone:937-403-5251
Mailing Address - Fax:
Practice Address - Street 1:4633 AICHOLTZ RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45244-1447
Practice Address - Country:US
Practice Address - Phone:513-752-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1500158101YM0800X
OHE.1901080101YP2500X
OHE.1901080-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health