Provider Demographics
NPI:1174091110
Name:JAQUISH, MICHELLE N (LICSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:N
Last Name:JAQUISH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6314 19TH ST W STE 7
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6223
Mailing Address - Country:US
Mailing Address - Phone:601-206-8735
Mailing Address - Fax:
Practice Address - Street 1:6314 19TH ST W STE 7
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6223
Practice Address - Country:US
Practice Address - Phone:601-206-8735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW611159061041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty