Provider Demographics
NPI:1326415662
Name:BAKER, JACQUELINE (REGISTERED IMH14441)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:REGISTERED IMH14441
Other - Prefix:
Other - First Name:NASHIDA
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:3601 W COMMERCIAL BLVD STE 35
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3329
Mailing Address - Country:US
Mailing Address - Phone:954-677-8787
Mailing Address - Fax:
Practice Address - Street 1:580 ELLIS RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-3582
Practice Address - Country:US
Practice Address - Phone:904-423-0017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health