Provider Demographics
NPI:1275694275
Name:MYERS, JACQUELINE ELEANOR (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ELEANOR
Last Name:MYERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JACQUELINE
Other - Middle Name:ELEANOR
Other - Last Name:HOBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 KAY LARKIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177
Mailing Address - Country:US
Mailing Address - Phone:386-329-3780
Mailing Address - Fax:386-329-3786
Practice Address - Street 1:330 KAY LARKIN DRIVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177
Practice Address - Country:US
Practice Address - Phone:386-329-3780
Practice Address - Fax:386-329-3786
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW78601041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL765929600Medicare ID - Type Unspecified