Provider Demographics
NPI:1134345176
Name:RAXTER, JACQUELINE MARIE (MA,LMSW,LPC)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:RAXTER
Suffix:
Gender:F
Credentials:MA,LMSW,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25839 CUNNINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-1487
Mailing Address - Country:US
Mailing Address - Phone:586-754-5933
Mailing Address - Fax:313-961-1047
Practice Address - Street 1:220 BAGLEY ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-1400
Practice Address - Country:US
Practice Address - Phone:313-961-4890
Practice Address - Fax:313-961-1047
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010344251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical