Provider Demographics
NPI:1710056254
Name:JAQUISH, DONALD (LMSW)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:
Last Name:JAQUISH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2328
Mailing Address - Country:US
Mailing Address - Phone:231-946-2575
Mailing Address - Fax:231-946-6638
Practice Address - Street 1:902 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2328
Practice Address - Country:US
Practice Address - Phone:231-946-2575
Practice Address - Fax:231-946-6638
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010140451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0891153Medicare ID - Type UnspecifiedMEDIARE PROVIDER ID