Healthcare Provider Details

I. General information

NPI: 1336354091
Provider Name (Legal Business Name): JAQUELYN LISS RESNICK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SW 29TH PL
GAINESVILLE FL
32601-9010
US

IV. Provider business mailing address

700 SW 29TH PL
GAINESVILLE FL
32601-9010
US

V. Phone/Fax

Practice location:
  • Phone: 352-392-1575
  • Fax: 352-392-8452
Mailing address:
  • Phone: 352-378-8223
  • Fax: 352-392-8453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY002780
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: