MEDICARE: JACQUELINE MICHEL WHITMORE GSW

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	104100000X	Social Worker	6729	LA

General Provider Information

NPI Number	:	1790995124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE MICHEL WHITMORE GSW

Provider Business Mailing Address
First Line	:	PO BOX 498
Second Line	:
City	:	JACKSON
State	:	LA
Zip	:	70748-0498
Country	:	US
Telephone Number	:	225-634-0224
Fax Number	:	225-634-0213

Provider Business Practice Location Address
First Line	:	4502 HWY.10
Second Line	:
City	:	JACKSON
State	:	LA
Zip	:	70748-0498
Country	:	US
Telephone Number	:	225-634-0224
Fax Number	:	225-634-0213

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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