Provider Demographics
NPI:1558417790
Name:VANCE, JACQUELINE SHEA (LCSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:SHEA
Last Name:VANCE
Suffix:
Gender:F
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7131
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-0041
Mailing Address - Country:US
Mailing Address - Phone:253-409-8803
Mailing Address - Fax:
Practice Address - Street 1:25227 161ST PL SE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4127
Practice Address - Country:US
Practice Address - Phone:253-409-8803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS#203781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW20378Medicare UPIN