Healthcare Provider Details

I. General information

NPI: 1194512293
Provider Name (Legal Business Name): JACQUELINE LEIGH (PREFERRED) MATHIS REGISTERED INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E TOWN PL UNIT 207
ST AUGUSTINE FL
32092-0664
US

IV. Provider business mailing address

2872 N 1ST ST
ST AUGUSTINE FL
32084-1942
US

V. Phone/Fax

Practice location:
  • Phone: 850-629-8242
  • Fax:
Mailing address:
  • Phone: 561-676-2529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH25564
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: