Healthcare Provider Details

I. General information

NPI: 1801670831
Provider Name (Legal Business Name): JACQUELINE DENISE WASHINGTON MENTAL HEALTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE DENISE WASHINGTON

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 DALLAS ST
GARY IN
46406-1327
US

IV. Provider business mailing address

224 DALLAS ST
GARY IN
46406-1327
US

V. Phone/Fax

Practice location:
  • Phone: 219-248-5307
  • Fax:
Mailing address:
  • Phone: 219-248-5307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: