=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144454554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER CLINARD PIQUER M.S., LMHC, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2009
-----------------------------------------------------
Last Update Date | 01/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11512 LAKE MEAD AVE SUITE 703
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-9680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-646-0054
-----------------------------------------------------
Fax | 904-646-0630
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11512 LAKE MEAD AVE SUITE 703
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-9680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-646-0054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH6272
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 62313
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------