Healthcare Provider Details

I. General information

NPI: 1184160590
Provider Name (Legal Business Name): JACLYN MATTHEWS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 GULF TO BAY BLVD STE 312
CLEARWATER FL
33759-4304
US

IV. Provider business mailing address

PO BOX 9478
BRADENTON FL
34206-9478
US

V. Phone/Fax

Practice location:
  • Phone: 727-279-0101
  • Fax:
Mailing address:
  • Phone: 941-782-4299
  • Fax: 941-782-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH14728
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: