Healthcare Provider Details

I. General information

NPI: 1194527895
Provider Name (Legal Business Name): JERICA MICHELE MCQUEEN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2025
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7985 COLEE COVE RD
ST AUGUSTINE FL
32092-2306
US

IV. Provider business mailing address

7985 COLEE COVE RD
ST AUGUSTINE FL
32092-2306
US

V. Phone/Fax

Practice location:
  • Phone: 904-322-1816
  • Fax:
Mailing address:
  • Phone: 904-322-1816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH25402
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: