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General NPI Number Information
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NPI Number | 1194512293
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Entity Type | Individual
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Provider Name | JACQUELINE LEIGH (PREFERRED) MATHIS REGISTERED INTERN
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Gender | Female
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Dates
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Enumeration Date | 04/22/2025
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 100 E TOWN PL UNIT 207
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City | ST AUGUSTINE
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State | FL
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Zip | 32092-0664
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Country | US
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Telephone | 850-629-8242
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Fax |
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Provider Business Mailing Address
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Address Line | 2872 N 1ST ST
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City | ST AUGUSTINE
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State | FL
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Zip | 32084-1942
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Country | US
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Telephone | 561-676-2529
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | IMH25564
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License Number State | FL
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