Healthcare Provider Details

I. General information

NPI: 1528687902
Provider Name (Legal Business Name): JACQUELINE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 OAKLEY SEAVER DR STE 307
CLERMONT FL
34711-1961
US

IV. Provider business mailing address

1230 OAKLEY SEAVER DR STE 307
CLERMONT FL
34711-1961
US

V. Phone/Fax

Practice location:
  • Phone: 352-988-6673
  • Fax:
Mailing address:
  • Phone: 352-988-6673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH16012
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: