Healthcare Provider Details

I. General information

NPI: 1598740896
Provider Name (Legal Business Name): JACQUELINE RITA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELINE RITA LMHC

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E INTERNATIONAL SPEEDWAY BLVD STE 107
DAYTONA BEACH FL
32118-4662
US

IV. Provider business mailing address

1225 RUTHBERN RD
DAYTONA BEACH FL
32114-5961
US

V. Phone/Fax

Practice location:
  • Phone: 401-486-6081
  • Fax: 386-401-2414
Mailing address:
  • Phone: 401-486-6081
  • Fax: 386-401-2414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11788
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00222
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: