Provider Demographics
NPI:1679237903
Name:JACQUART, JOLENE (PHD)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:JACQUART
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 N SWAN RD STE 206
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1259
Mailing Address - Country:US
Mailing Address - Phone:520-230-1065
Mailing Address - Fax:
Practice Address - Street 1:3075 N SWAN RD STE 206
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1259
Practice Address - Country:US
Practice Address - Phone:520-230-1065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5349103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral