Provider Demographics
NPI:1770889354
Name:TAGUE, JACQUE LYNN (LMSW, LAC)
Entity type:Individual
Prefix:MS
First Name:JACQUE
Middle Name:LYNN
Last Name:TAGUE
Suffix:
Gender:F
Credentials:LMSW, LAC
Other - Prefix:MS
Other - First Name:JACQUE
Other - Middle Name:LYNN
Other - Last Name:TAGUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW, LAC
Mailing Address - Street 1:555 N WOODLAWN ST STE 102
Mailing Address - Street 2:3105
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3671
Mailing Address - Country:US
Mailing Address - Phone:316-652-2590
Mailing Address - Fax:316-652-2595
Practice Address - Street 1:555 N WOODLAWN ST STE 102
Practice Address - Street 2:3105
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3671
Practice Address - Country:US
Practice Address - Phone:316-652-2590
Practice Address - Fax:316-652-2595
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7528104100000X
KS378101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200714670AMedicaid