Provider Demographics
NPI:1982596243
Name:FOUNTAIN, JACQUELINE (LAAC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:LAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E SECOND ST
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-3704
Mailing Address - Country:US
Mailing Address - Phone:928-358-9370
Mailing Address - Fax:928-358-9370
Practice Address - Street 1:110 E SECOND ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-3704
Practice Address - Country:US
Practice Address - Phone:602-989-3276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-19
Last Update Date:2025-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAAC15465101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)