Provider Demographics
NPI:1821402843
Name:JACQUELYN BAINBRIDGE
Entity Type:Organization
Organization Name:JACQUELYN BAINBRIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPCC
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAINBRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-445-8376
Mailing Address - Street 1:30 PORTAGE PL
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-5782
Mailing Address - Country:US
Mailing Address - Phone:502-445-8376
Mailing Address - Fax:
Practice Address - Street 1:30 PORTAGE PL
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-5782
Practice Address - Country:US
Practice Address - Phone:502-445-8376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCPCC00223151251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health