Provider Demographics
NPI:1659946432
Name:WARMAN, JACQUELINE R (LADC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:R
Last Name:WARMAN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 286
Mailing Address - Street 2:
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072-0286
Mailing Address - Country:US
Mailing Address - Phone:320-245-9966
Mailing Address - Fax:
Practice Address - Street 1:413 COMMERCIAL AVE N
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-4412
Practice Address - Country:US
Practice Address - Phone:320-245-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305588101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty