Basic Information
| Provider Information | |||||||||
| NPI: | 1457760696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VEGA | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544864005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3199 LAKE WORTH RD | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334613652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616496500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2014 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MH13472 | FL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | MH13472 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.