Provider Demographics
NPI:1134660996
Name:DONOVAN, JACQUELINE NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:886-610-0580
Mailing Address - Fax:886-610-0580
Practice Address - Street 1:7000 LAKE ELLENOR DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-5749
Practice Address - Country:US
Practice Address - Phone:321-655-6585
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-19-37212103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009093700Medicaid