Healthcare Provider Details

I. General information

NPI: 1588111637
Provider Name (Legal Business Name): JACQUELINE WALLISCHECK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 W ELM ST
WAUSEON OH
43567-1146
US

IV. Provider business mailing address

259 W ELM ST
WAUSEON OH
43567-1146
US

V. Phone/Fax

Practice location:
  • Phone: 419-337-0130
  • Fax:
Mailing address:
  • Phone: 419-337-0130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0901505
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: