Provider Demographics
NPI:1508373978
Name:CONGER, JACQUELINE MARIE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:CONGER
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 1:814 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4019
Mailing Address - Country:US
Mailing Address - Phone:734-536-6116
Mailing Address - Fax:
Practice Address - Street 1:13561 S WEST BAY SHORE DR STE 204
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6292
Practice Address - Country:US
Practice Address - Phone:734-536-6116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-06
Last Update Date:2018-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016298101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health