Provider Demographics
NPI:1437300100
Name:DAVIS, JACQUI (MS PSYCHOLOGY, LPC)
Entity Type:Individual
Prefix:MS
First Name:JACQUI
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS PSYCHOLOGY, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 WILLIAMS HWY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5660
Mailing Address - Country:US
Mailing Address - Phone:541-660-0436
Mailing Address - Fax:
Practice Address - Street 1:1215 SW G ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2544
Practice Address - Country:US
Practice Address - Phone:541-472-5845
Practice Address - Fax:541-476-1526
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2052101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional