Provider Demographics
NPI:1225485493
Name:NALLEY, JACKIE (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:NALLEY
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 SW AQUARIUS LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4486
Mailing Address - Country:US
Mailing Address - Phone:734-564-2148
Mailing Address - Fax:
Practice Address - Street 1:1100 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3823
Practice Address - Country:US
Practice Address - Phone:772-320-0770
Practice Address - Fax:772-320-0181
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22847101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health