Provider Demographics
NPI:1548717903
Name:JACQUETTE, AUTUMN RENEE (LGSW)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:RENEE
Last Name:JACQUETTE
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:ROCK HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21661-0591
Mailing Address - Country:US
Mailing Address - Phone:410-310-8917
Mailing Address - Fax:
Practice Address - Street 1:5878 HENRY AVE
Practice Address - Street 2:
Practice Address - City:ROCK HALL
Practice Address - State:MD
Practice Address - Zip Code:21661-1342
Practice Address - Country:US
Practice Address - Phone:410-310-8917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-02
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21142104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker