Provider Demographics
NPI:1497743504
Name:WALLACE, JACQUELINE D (MSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 JENKS ST
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-1640
Mailing Address - Country:US
Mailing Address - Phone:413-253-5457
Mailing Address - Fax:
Practice Address - Street 1:447 WEST ST
Practice Address - Street 2:SUITE #3
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-2933
Practice Address - Country:US
Practice Address - Phone:413-253-2893
Practice Address - Fax:413-253-2893
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10166381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical