MEDICARE: JACQUELINE RITA LMHC

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	11788	FL
2	101YM0800X	Mental Health Counselor	00222	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	27972-1	OTHER	RI	BLUE CROSS
2	412090	OTHER	RI	BLUE CHIP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598740896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE RITA LMHC

Provider Business Mailing Address
First Line	:	1225 RUTHBERN RD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-5961
Country	:	US
Telephone Number	:	401-486-6081
Fax Number	:	386-401-2414

Provider Business Practice Location Address
First Line	:	211 E INTERNATIONAL SPEEDWAY BLVD STE 107
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32118-4662
Country	:	US
Telephone Number	:	401-486-6081
Fax Number	:	386-401-2414

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

Provider Enumeration Date	:	12/08/2005
Last Update Date	:	03/03/2025

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