Provider Demographics
NPI:1306972336
Name:DOUGHERTY, JACINDA ELAINE (PSYD)
Entity type:Individual
Prefix:
First Name:JACINDA
Middle Name:ELAINE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JACIE
Other - Middle Name:
Other - Last Name:TRAUTWEIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3757 S. GREYSTONE CT.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-0000
Mailing Address - Country:US
Mailing Address - Phone:417-877-7500
Mailing Address - Fax:417-877-7600
Practice Address - Street 1:3757 S. GREYSTONE CT.
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-0000
Practice Address - Country:US
Practice Address - Phone:417-877-7500
Practice Address - Fax:417-877-7600
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001031418103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152184OtherBLUE SHIELD
MO495693707Medicaid
MO152184OtherBLUE SHIELD