Provider Demographics
NPI:1538272414
Name:WILLIAMS, JACQUELINE E (MSSW LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:E
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MSSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1230
Mailing Address - Country:US
Mailing Address - Phone:812-423-7791
Mailing Address - Fax:812-422-7558
Practice Address - Street 1:315 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-1723
Practice Address - Country:US
Practice Address - Phone:812-897-4776
Practice Address - Fax:812-422-7558
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000260A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100240880Medicaid
IN000000176974OtherANTHEM
IN800006336OtherRAILROAD
IN11491184OtherCAQH
IN839090GMedicare ID - Type Unspecified