Provider Demographics
NPI:1992290381
Name:MCRAE, JACQUELINE VENESIA (ICS, SAC-IT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:VENESIA
Last Name:MCRAE
Suffix:
Gender:F
Credentials:ICS, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 NORTHWESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-1504
Mailing Address - Country:US
Mailing Address - Phone:262-637-9984
Mailing Address - Fax:262-637-9995
Practice Address - Street 1:4810 NORTHWESTERN AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-1504
Practice Address - Country:US
Practice Address - Phone:262-637-9984
Practice Address - Fax:262-637-9995
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18414-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)