Provider Demographics
NPI:1972040210
Name:MADISON, JACQUELINE JUANITA (DMIN,MA, CAPS, LPC)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:JUANITA
Last Name:MADISON
Suffix:
Gender:F
Credentials:DMIN,MA, CAPS, LPC
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:J
Other - Last Name:MADISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REV DR
Mailing Address - Street 1:5343 BELLEVILLE CROSSING ST # 2079
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-3108
Mailing Address - Country:US
Mailing Address - Phone:314-740-0903
Mailing Address - Fax:314-448-1481
Practice Address - Street 1:5655 KINGSBURY AVE APT 909
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-1874
Practice Address - Country:US
Practice Address - Phone:314-740-0903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP1600X, 171400000X
IL178.012744101YM0800X
1090171400000X
IL101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171400000XOther Service ProvidersHealth & Wellness Coach