Healthcare Provider Details

I. General information

NPI: 1407656127
Provider Name (Legal Business Name): BROOKE COUNSELING SERVICES CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2025
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 SEGOVIA RD OFC
ST AUGUSTINE FL
32086-6456
US

IV. Provider business mailing address

PO BOX 806
ST AUGUSTINE FL
32085-0806
US

V. Phone/Fax

Practice location:
  • Phone: 904-806-1812
  • Fax:
Mailing address:
  • Phone: 904-806-1812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE DOUGHERTY
Title or Position: DIRECTOR
Credential: MS LMHC OS
Phone: 904-806-1812