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:W6188 EVERGLADE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-8590
Mailing Address - Country:US
Mailing Address - Phone:920-268-3242
Mailing Address - Fax:
Practice Address - Street 1:W6188 EVERGLADE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942-8590
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:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor