Provider Demographics
NPI:1851593206
Name:SOULLIERE, JACQUIE MARY (LMSW, CACR)
Entity Type:Individual
Prefix:MRS
First Name:JACQUIE
Middle Name:MARY
Last Name:SOULLIERE
Suffix:
Gender:F
Credentials:LMSW, CACR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 MARENTETTE AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N8X4C6
Mailing Address - Country:CA
Mailing Address - Phone:519-254-9905
Mailing Address - Fax:
Practice Address - Street 1:26184 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2084
Practice Address - Country:US
Practice Address - Phone:313-389-2209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010714261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical