MEDICARE: JACQUELYN LISETTE GARCIA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	SW12176	FL
2	1041C0700X	Clinical Social Worker	C009370	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235521287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN LISETTE GARCIA LCSW

Provider Business Mailing Address
First Line	:	1935 J N PEASE PL STE 102
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4541
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1935 J N PEASE PL STE 102
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4541
Country	:	US
Telephone Number	:	954-608-7446
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2015
Last Update Date	:	05/09/2017

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