Provider Demographics
NPI:1851772487
Name:LOB, JACQUELINE (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LOB
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10420 OLD OLIVE STREET ROAD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5937
Mailing Address - Country:US
Mailing Address - Phone:314-504-4698
Mailing Address - Fax:314-692-9978
Practice Address - Street 1:10420 OLD OLIVE STREET ROAD
Practice Address - Street 2:SUITE 205
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5937
Practice Address - Country:US
Practice Address - Phone:314-504-4698
Practice Address - Fax:314-692-9978
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140321201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical