Provider Demographics
NPI:1801670831
Name:WASHINGTON, JACQUELINE DENISE (MENTAL HEALTH)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DENISE
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:MENTAL HEALTH
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:DENISE
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:224 DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46406-1327
Mailing Address - Country:US
Mailing Address - Phone:219-248-5307
Mailing Address - Fax:
Practice Address - Street 1:224 DALLAS ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46406-1327
Practice Address - Country:US
Practice Address - Phone:219-248-5307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness