Basic Information
| Provider Information | |||||||||
| NPI: | 1770889354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAGUE | ||||||||
| FirstName: | JACQUE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW, LAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAGUE | ||||||||
| OtherFirstName: | JACQUE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW, LAC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 555 N WOODLAWN ST STE 102 | ||||||||
| Address2: | 3105 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166522590 | ||||||||
| FaxNumber: | 3166522595 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 N WOODLAWN ST STE 102 | ||||||||
| Address2: | 3105 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672083671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166522590 | ||||||||
| FaxNumber: | 3166522595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2011 | ||||||||
| LastUpdateDate: | 12/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 7528 | KS | Y | Behavioral Health & Social Service Providers | Social Worker | 101Y00000X | 378 | KS | N | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 200714670A | 05 | KS | MEDICAID |