Provider Demographics
NPI:1184922189
Name:DALE, JEANIE (MA, LPC)
Entity type:Individual
Prefix:
First Name:JEANIE
Middle Name:
Last Name:DALE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5044
Mailing Address - Country:US
Mailing Address - Phone:573-803-1402
Mailing Address - Fax:
Practice Address - Street 1:1353 N MOUNT AUBURN RD
Practice Address - Street 2:SUITE C
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-1727
Practice Address - Country:US
Practice Address - Phone:573-803-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002485101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional