Basic Information
| Provider Information | |||||||||
| NPI: | 1952585622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | TANIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOSTER | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | TANIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 SOUTHERN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425013223 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 MEDICAL LANE | ||||||||
| Address2: | |||||||||
| City: | WHITLEY CITY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063762466 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2007 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.