Healthcare Provider Details

I. General information

NPI: 1518053776
Provider Name (Legal Business Name): JACKIE DOWNIE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACKIE DOWNIE MSW

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 EAST PINE STREET SUITE 104
PINEDALE WY
82941-0484
US

IV. Provider business mailing address

PO BOX 484
PINEDALE WY
82941-0484
US

V. Phone/Fax

Practice location:
  • Phone: 307-367-4118
  • Fax:
Mailing address:
  • Phone: 307-367-4118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL2425
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: