Provider Demographics
NPI:1073924700
Name:FLYNN, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FLYNN
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 1:5235 DEVON ST
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-2929
Mailing Address - Country:US
Mailing Address - Phone:321-544-2743
Mailing Address - Fax:
Practice Address - Street 1:846 NORTH COCOA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-3623
Practice Address - Country:US
Practice Address - Phone:321-544-2743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13594101YM0800X, 101YP2500X
FL1080175101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool