Provider Demographics
NPI:1265671150
Name:WASHINGTON, JACQUE TARA (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUE
Middle Name:TARA
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E. GREEN ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5421
Mailing Address - Country:US
Mailing Address - Phone:607-274-6230
Mailing Address - Fax:607-274-6316
Practice Address - Street 1:201 E. GREEN ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5421
Practice Address - Country:US
Practice Address - Phone:607-274-6230
Practice Address - Fax:607-274-6316
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075193-1101YM0800X
NY080091-11041C0700X
NYR0800911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health