Healthcare Provider Details

I. General information

NPI: 1891053427
Provider Name (Legal Business Name): JQM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 PASEO REYES DR
ST AUGUSTINE FL
32095-8464
US

IV. Provider business mailing address

344 PASEO REYES DR
ST AUGUSTINE FL
32095-8464
US

V. Phone/Fax

Practice location:
  • Phone: 904-347-0751
  • Fax:
Mailing address:
  • Phone: 904-755-6592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7659
License Number StateFL

VIII. Authorized Official

Name: DR. CHRISTY LOUISE MONAGHAN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 904-347-0751