Provider Demographics
NPI:1588251003
Name:CAVANAGH, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CAVANAGH
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:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:WV
Mailing Address - Zip Code:26801-0097
Mailing Address - Country:US
Mailing Address - Phone:304-897-5915
Mailing Address - Fax:
Practice Address - Street 1:22347 NORTHWESTERN PIKE
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-6343
Practice Address - Country:US
Practice Address - Phone:304-822-6616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV102101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health