Provider Demographics
NPI:1740309129
Name:WELBORN, JACQUELINE S (MA, PLPC, CSACII)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:S
Last Name:WELBORN
Suffix:
Gender:F
Credentials:MA, PLPC, CSACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N PINE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3141
Mailing Address - Country:US
Mailing Address - Phone:573-426-2588
Mailing Address - Fax:
Practice Address - Street 1:107 HISTORIC 66 E
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2643
Practice Address - Country:US
Practice Address - Phone:573-528-1292
Practice Address - Fax:888-554-6133
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007008181101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional