Provider Demographics
NPI:1417189887
Name:SPEAKE, JACQUELYN (LPCC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:SPEAKE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 N BEHREND AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8414
Mailing Address - Country:US
Mailing Address - Phone:505-326-2736
Mailing Address - Fax:505-325-2127
Practice Address - Street 1:114 N BEHREND AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8414
Practice Address - Country:US
Practice Address - Phone:505-326-2736
Practice Address - Fax:505-325-2127
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0123811101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health