Provider Demographics
NPI:1427874742
Name:BAXTER, JACEY WILEMON (LCSW)
Entity type:Individual
Prefix:
First Name:JACEY
Middle Name:WILEMON
Last Name:BAXTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JAYCEE
Other - Middle Name:ALYCE
Other - Last Name:WILEMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSW
Mailing Address - Street 1:614 MOOSE ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:CO
Mailing Address - Zip Code:80530-8060
Mailing Address - Country:US
Mailing Address - Phone:512-585-1429
Mailing Address - Fax:
Practice Address - Street 1:614 MOOSE ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:CO
Practice Address - Zip Code:80530-8060
Practice Address - Country:US
Practice Address - Phone:512-585-1429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099310481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical