Healthcare Provider Details

I. General information

NPI: 1174848535
Provider Name (Legal Business Name): JACQUELINE DAVIS LCPC, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7403 CLINE AVE
SCHERERVILLE IN
46375-2645
US

IV. Provider business mailing address

7403 CLINE AVE
SCHERERVILLE IN
46375-2645
US

V. Phone/Fax

Practice location:
  • Phone: 219-322-8614
  • Fax: 219-322-8502
Mailing address:
  • Phone: 219-322-8614
  • Fax: 219-322-8502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180.006831
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002046A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: