Provider Demographics
NPI:1851906184
Name:DETRICK, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DETRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4822 TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:SUTHERLAND
Mailing Address - State:IA
Mailing Address - Zip Code:51058-7572
Mailing Address - Country:US
Mailing Address - Phone:712-441-2305
Mailing Address - Fax:
Practice Address - Street 1:118 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IA
Practice Address - Zip Code:51201-1039
Practice Address - Country:US
Practice Address - Phone:712-262-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)