Provider Demographics
NPI:1477140085
Name:MALCOLM, JACQUELINE (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:MALCOLM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW-P
Mailing Address - Street 1:1001 WEST STREET
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-9703
Mailing Address - Country:US
Mailing Address - Phone:315-519-5724
Mailing Address - Fax:315-493-0105
Practice Address - Street 1:3 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-1360
Practice Address - Country:US
Practice Address - Phone:315-493-3300
Practice Address - Fax:315-493-3306
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107501-01104100000X
NY0993911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker