Provider Demographics
NPI:1720576028
Name:VICK, JACQUELINE MARIA
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIA
Last Name:VICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MARIA
Other - Last Name:KONKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:8411 S FORK DR
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55921-3736
Mailing Address - Country:US
Mailing Address - Phone:075-429-5018
Mailing Address - Fax:
Practice Address - Street 1:1575 ALLOUEZ AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5639
Practice Address - Country:US
Practice Address - Phone:507-429-5018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN309411OtherMN DEPT OF ED