Provider Demographics
NPI:1952061715
Name:FALL, JACQUELINE (BA, MHP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FALL
Suffix:
Gender:F
Credentials:BA, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 S FAIRMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52802-3644
Mailing Address - Country:US
Mailing Address - Phone:563-322-2667
Mailing Address - Fax:
Practice Address - Street 1:1523 S FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52802-3644
Practice Address - Country:US
Practice Address - Phone:563-322-2667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)