Basic Information
| Provider Information | |||||||||
| NPI: | 1922447200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN-BUNK | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19249 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322459249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047431883 | ||||||||
| FaxNumber: | 9047435109 | ||||||||
| Practice Location | |||||||||
| Address1: | 4412 BARNES RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322077469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047306288 | ||||||||
| FaxNumber: | 9047395339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2013 | ||||||||
| LastUpdateDate: | 03/27/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH 11830 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 008922800 | 05 | FL | MEDICAID |