MEDICARE: JACLYN MATTHEWS LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH14728	FL

General Provider Information

NPI Number	:	1184160590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN MATTHEWS LMHC

Provider Business Mailing Address
First Line	:	PO BOX 9478
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34206-9478
Country	:	US
Telephone Number	:	941-782-4299
Fax Number	:	941-782-4301

Provider Business Practice Location Address
First Line	:	3000 GULF TO BAY BLVD STE 312
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33759-4304
Country	:	US
Telephone Number	:	727-279-0101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2017
Last Update Date	:	07/02/2020

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