Provider Demographics
NPI:1699133959
Name:BALLOU, JACQUELINE (MSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BALLOU
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50138-2301
Mailing Address - Country:US
Mailing Address - Phone:641-891-4997
Mailing Address - Fax:
Practice Address - Street 1:210 S 1ST ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138-2301
Practice Address - Country:US
Practice Address - Phone:641-891-4997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA121270104100000X
CO0009922098104100000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid