Provider Demographics
NPI:1629108204
Name:DWYER, JACQUELINE CARRINGTON (MS, LPC, LBSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:CARRINGTON
Last Name:DWYER
Suffix:
Gender:F
Credentials:MS, LPC, LBSW
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:CARRINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 LONGVIEW ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-5929
Mailing Address - Country:US
Mailing Address - Phone:989-496-7229
Mailing Address - Fax:
Practice Address - Street 1:1321 S FAYETTE ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-1447
Practice Address - Country:US
Practice Address - Phone:989-792-8000
Practice Address - Fax:989-792-8445
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802063706104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker