Provider Demographics
NPI:1447493192
Name:WILLIAMS, JACQUELINE L
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3599 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3417
Mailing Address - Country:US
Mailing Address - Phone:407-956-5773
Mailing Address - Fax:
Practice Address - Street 1:3599 W LAKE MARY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3417
Practice Address - Country:US
Practice Address - Phone:407-956-5773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 2384106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist