Provider Demographics
NPI:1588949135
Name:CODY, JACQUELYN A (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:A
Last Name:CODY
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:A
Other - Last Name:JAKUBOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LICSW
Mailing Address - Street 1:115 5TH AVE. S.
Mailing Address - Street 2:PEACE OF MIND COUNSELING, LLC
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4018
Mailing Address - Country:US
Mailing Address - Phone:608-797-5679
Mailing Address - Fax:608-782-4426
Practice Address - Street 1:115 5TH AVE. S.
Practice Address - Street 2:PEACE OF MIND COUNSELING, LLC
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4018
Practice Address - Country:US
Practice Address - Phone:608-797-5679
Practice Address - Fax:608-782-4426
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7787-123104100000X
MN21324104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1588949135Medicaid
MN1588949135Medicaid
MN1588949135Medicaid
WI1588949135Medicaid