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General NPI Number Information
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NPI Number | 1174091110
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Entity Type | Individual
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Provider Name | MICHELLE N JAQUISH LICSW
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Gender | Female
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Dates
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Enumeration Date | 11/07/2018
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Last Update Date | 01/13/2025
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Provider Practice Location Address
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Address Line | 6314 19TH ST W STE 7
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City | FIRCREST
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State | WA
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Zip | 98466-6223
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Country | US
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Telephone | 601-206-8735
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Fax |
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Provider Business Mailing Address
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Address Line | 6314 19TH ST W STE 7
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City | FIRCREST
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State | WA
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Zip | 98466-6223
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Country | US
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Telephone | 601-206-8735
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LW61115906
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License Number State | WA
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