Provider Demographics
NPI:1588700397
Name:LEGETTE, JACQUELINE THERESA (MA)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:THERESA
Last Name:LEGETTE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:THERESA
Other - Last Name:BOSTICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1340 LONGCREEK DR
Mailing Address - Street 2:APT. 1006
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-7182
Mailing Address - Country:US
Mailing Address - Phone:803-750-5026
Mailing Address - Fax:
Practice Address - Street 1:1800 COLONIAL DR
Practice Address - Street 2:NETWORK PROGRAM
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6827
Practice Address - Country:US
Practice Address - Phone:803-898-1555
Practice Address - Fax:803-898-2194
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health