Provider Demographics
NPI:1558055004
Name:THOMAS, JACQUELYN RENEE (MAC, ICAADC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:RENEE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MAC, ICAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 NORWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1124
Mailing Address - Country:US
Mailing Address - Phone:676-789-9480
Mailing Address - Fax:678-623-9777
Practice Address - Street 1:108 NORWOOD DR
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1124
Practice Address - Country:US
Practice Address - Phone:676-789-9480
Practice Address - Fax:678-623-9777
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3545101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty