Provider Demographics
NPI:1659420339
Name:PSOTA, JACQUELIN NICKOLE (LCP)
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:NICKOLE
Last Name:PSOTA
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-6127
Mailing Address - Country:US
Mailing Address - Phone:620-794-8616
Mailing Address - Fax:
Practice Address - Street 1:614 MERCHANT ST
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-2859
Practice Address - Country:US
Practice Address - Phone:620-794-8616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1495103T00000X
KS926103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist