Provider Demographics
NPI:1548816333
Name:LISZEWSKI, JACQUELINE (LCSW, MATS)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LISZEWSKI
Suffix:
Gender:F
Credentials:LCSW, MATS
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:DORANTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW, MATS
Mailing Address - Street 1:8000 MELTON RD
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-3114
Mailing Address - Country:US
Mailing Address - Phone:219-938-4651
Mailing Address - Fax:219-938-4679
Practice Address - Street 1:8000 MELTON RD
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-3114
Practice Address - Country:US
Practice Address - Phone:219-938-4651
Practice Address - Fax:219-938-4679
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34010715A1041C0700X
IN33008998A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical