Provider Demographics
NPI:1679193759
Name:ALDRICH, JACQUELINE M (BSW, BI)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:M
Last Name:ALDRICH
Suffix:
Gender:F
Credentials:BSW, BI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 12TH STREET C
Mailing Address - Street 2:3407 12TH STREET C
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-790-0132
Mailing Address - Fax:
Practice Address - Street 1:3407 12TH STREET C
Practice Address - Street 2:3407 12TH STREET C
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-790-0132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician