Provider Demographics
NPI:1134548860
Name:VANCE, JACLYN (LICSW)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S. TWINING ST, BLDG 760
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36112-6219
Mailing Address - Country:US
Mailing Address - Phone:334-953-5430
Mailing Address - Fax:
Practice Address - Street 1:300 S. TWINING ST, BLDG 760
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36112-6219
Practice Address - Country:US
Practice Address - Phone:334-953-5430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3591C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical