Provider Demographics
NPI:1851520407
Name:ANDERSON, JACQUELINE MARIE (MAC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 HUMMINGBIRD LN STE H
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-5607
Mailing Address - Country:US
Mailing Address - Phone:920-268-3242
Mailing Address - Fax:888-335-6058
Practice Address - Street 1:1011 N LYNNDALE DR STE 2D
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3091
Practice Address - Country:US
Practice Address - Phone:920-268-3242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-03
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor