Provider Demographics
NPI:1497208110
Name:BORTHWICK, JACQUELINE
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:BORTHWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3467
Mailing Address - Country:US
Mailing Address - Phone:262-695-8857
Mailing Address - Fax:262-695-8879
Practice Address - Street 1:161 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3467
Practice Address - Country:US
Practice Address - Phone:262-695-8857
Practice Address - Fax:262-695-8879
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3354-57103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent