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General NPI Number Information
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NPI Number | 1528527231
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Entity Type | Organization
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Legal Business Name | JACQUELINE C EKSTROM LCSW LLC
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Dates
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Enumeration Date | 03/13/2019
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Last Update Date | 03/13/2019
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Provider Practice Location Address
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Address Line | 1103 9TH AVE W
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City | BRADENTON
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State | FL
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Zip | 34205-7717
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Country | US
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Telephone | 941-218-0061
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Fax |
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Provider Business Mailing Address
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Address Line | 4207 5TH AVE NE
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City | BRADENTON
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State | FL
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Zip | 34208-5000
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JACQUELINE C EKSTROM
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Credential | LCSW
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Telephone | 941-218-0061
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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