Provider Demographics
NPI:1659555035
Name:MCCULLOUGH, JACQUELINE DOREEN (LBSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:DOREEN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3066 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-4801
Mailing Address - Country:US
Mailing Address - Phone:734-344-6087
Mailing Address - Fax:
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020820021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical