MEDICARE: MS. JACQUELYN RENEE THOMAS MAC, ICAADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	3545	VA

General Provider Information

NPI Number	:	1558055004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACQUELYN RENEE THOMAS MAC, ICAADC

Provider Business Mailing Address
First Line	:	108 NORWOOD DR
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-1124
Country	:	US
Telephone Number	:	676-789-9480
Fax Number	:	678-623-9777

Provider Business Practice Location Address
First Line	:	108 NORWOOD DR
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-1124
Country	:	US
Telephone Number	:	676-789-9480
Fax Number	:	678-623-9777

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2023
Last Update Date	:	06/07/2023

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