Provider Demographics
NPI:1255995213
Name:WONDOLOWSKI, JACQUELINE A (LMSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:WONDOLOWSKI
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 1:350 LAFAYETTE AVE SE STE 301
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4656
Mailing Address - Country:US
Mailing Address - Phone:616-458-0801
Mailing Address - Fax:616-458-4065
Practice Address - Street 1:350 LAFAYETTE AVE SE STE 301
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4656
Practice Address - Country:US
Practice Address - Phone:616-458-0801
Practice Address - Fax:616-458-4065
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801021654104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker