Provider Demographics
NPI:1114066461
Name:PEPPER, JACQUELINE B (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:B
Last Name:PEPPER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N UNIVERSITY DR
Mailing Address - Street 2:STE 203
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-8919
Mailing Address - Country:US
Mailing Address - Phone:954-345-2292
Mailing Address - Fax:954-341-8101
Practice Address - Street 1:1515 N UNIVERSITY DR
Practice Address - Street 2:SUITE 202
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-6096
Practice Address - Country:US
Practice Address - Phone:954-345-2292
Practice Address - Fax:954-341-8101
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6102103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54571OtherBC BS NUMBER
FLZ7205BMedicare PIN