Provider Demographics
NPI:1942815444
Name:HITCHCOCK, JACQUELYN SHAE (LMSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:SHAE
Last Name:HITCHCOCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 LONE HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-7762
Mailing Address - Country:US
Mailing Address - Phone:417-813-9117
Mailing Address - Fax:
Practice Address - Street 1:1212 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2720
Practice Address - Country:US
Practice Address - Phone:417-865-1646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020027688104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker