Provider Demographics
NPI:1417658378
Name:NIEMANN, JAQUELINE
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
Last Name:NIEMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31654 DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FORISTELL
Mailing Address - State:MO
Mailing Address - Zip Code:63348-2570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1909 HILLBROOKE TRL STE 3
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-7902
Practice Address - Country:US
Practice Address - Phone:972-351-0078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-257009106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician