Individual
MS. JACQUELYN MAE BLOCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MFT, LCSW, LMFT
Contact information
Practice address
430 E DIVISION ST, FOND DU LAC, WI 54935-4560
(920) 926-4209
Mailing address
420 E DIVISION ST, FOND DU LAC, WI 54935-4560
(920) 926-4209
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
2841-123
WI
106H00000X
Marriage & Family Therapist
226-124
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
226-124
LMFT
WI
01
—
2841-123
LCSW
WI
Enumeration date
05/02/2007
Last updated
12/16/2020
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