Healthcare Provider Details

I. General information

NPI: 1366157224
Provider Name (Legal Business Name): JACKELINE LAURA LARA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25520 SORRENTO AVE
SORRENTO FL
32776-9632
US

IV. Provider business mailing address

25520 SORRENTO AVE
SORRENTO FL
32776-9632
US

V. Phone/Fax

Practice location:
  • Phone: 786-294-3186
  • Fax:
Mailing address:
  • Phone: 786-294-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21252
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: