Provider Demographics
NPI:1225651540
Name:VALLINA, JAQUELINE ROSE (LMSW)
Entity Type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:ROSE
Last Name:VALLINA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 GONWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1631
Mailing Address - Country:US
Mailing Address - Phone:954-793-5986
Mailing Address - Fax:
Practice Address - Street 1:340 GONWOOD CIR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1631
Practice Address - Country:US
Practice Address - Phone:954-793-5986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0086781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical