Provider Demographics
NPI:1477114957
Name:PROVENZOLA, JACQUELYN MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:PROVENZOLA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4902 CHILSON RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-9453
Mailing Address - Country:US
Mailing Address - Phone:248-385-2524
Mailing Address - Fax:844-640-0684
Practice Address - Street 1:4902 CHILSON RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-9453
Practice Address - Country:US
Practice Address - Phone:248-385-2524
Practice Address - Fax:844-640-0684
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
68011050071041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical