Basic Information
| Provider Information | |||||||||
| NPI: | 1588788822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCOUGHLAN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.ED., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 S 7TH ST | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824013308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073476165 | ||||||||
| FaxNumber: | 3073476166 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 S 7TH ST | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824013308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073476165 | ||||||||
| FaxNumber: | 3073476166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 04/19/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC-225 | WY | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | LPC-225 | WY | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 2329331 | 01 | WY | CIGNA BEHAVIORAL HEALTH | OTHER | 106352903 | 05 | WY | MEDICAID | 313612 | 01 | WY | BLUECROSS BLUESHIELD | OTHER | 106352900 | 05 | WY | MEDICAID |