Provider Demographics
NPI:1588841837
Name:TODD, JACQUELINE (MA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TODD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113A S DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-3447
Mailing Address - Country:US
Mailing Address - Phone:662-843-9445
Mailing Address - Fax:662-843-9447
Practice Address - Street 1:113A S DAVIS AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-3447
Practice Address - Country:US
Practice Address - Phone:662-843-9445
Practice Address - Fax:662-843-9447
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018205Medicaid