=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023639499
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACQUE RUCH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2020
-----------------------------------------------------
Last Update Date | 04/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3205 SOUTHGATE CIR STE 19
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34239-5514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-243-8332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11519 SWEETGRASS DR
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34212-2522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-243-8332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JACQUELYN J RUCH
-----------------------------------------------------
Credential | LCSW 8152438332
-----------------------------------------------------
Telephone | 815-243-8332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------