Provider Demographics
NPI:1629321815
Name:CARTER, JAQUELINE TOLLESON (LPC/MHSP)
Entity Type:Individual
Prefix:MRS
First Name:JAQUELINE
Middle Name:TOLLESON
Last Name:CARTER
Suffix:
Gender:F
Credentials:LPC/MHSP
Other - Prefix:MISS
Other - First Name:JAQUELINE
Other - Middle Name:TAREAS
Other - Last Name:TOLLESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1045 CHURCH RD E STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9702
Mailing Address - Country:US
Mailing Address - Phone:662-235-9063
Mailing Address - Fax:662-536-7439
Practice Address - Street 1:1045 CHURCH RD E STE 2
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9702
Practice Address - Country:US
Practice Address - Phone:662-235-9063
Practice Address - Fax:662-536-7439
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1733101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2701OtherLPC/MHSP
MS27-2955562OtherDESOTO FAMILY COUNSELING CENTER, PLLC