Provider Demographics
NPI:1902528045
Name:LIST-HOUSER, JACQUELINE DIANE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DIANE
Last Name:LIST-HOUSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-1539
Mailing Address - Country:US
Mailing Address - Phone:989-672-6160
Mailing Address - Fax:
Practice Address - Street 1:126 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-5846
Practice Address - Country:US
Practice Address - Phone:989-672-6160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty