Provider Demographics
NPI:1689858300
Name:RANCOUR, JACQUELINE M (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:M
Last Name:RANCOUR
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22753 NONA ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2621
Mailing Address - Country:US
Mailing Address - Phone:313-318-1237
Mailing Address - Fax:734-287-1660
Practice Address - Street 1:18518 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1874
Practice Address - Country:US
Practice Address - Phone:313-318-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010841031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN94410011Medicare UPIN