Provider Demographics
NPI:1477220598
Name:PUDLOWSKI, JACQUELINE SUE (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUE
Last Name:PUDLOWSKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 THUNDER HILL DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-4094
Mailing Address - Country:US
Mailing Address - Phone:314-409-0021
Mailing Address - Fax:
Practice Address - Street 1:789 THUNDER HILL DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-4094
Practice Address - Country:US
Practice Address - Phone:314-409-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040067771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty