Provider Demographics
NPI:1326769506
Name:CLOE, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CLOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 DWELL WELL WAY APT 1214
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-8930
Mailing Address - Country:US
Mailing Address - Phone:772-332-8451
Mailing Address - Fax:
Practice Address - Street 1:1300 N SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3557
Practice Address - Country:US
Practice Address - Phone:321-890-4038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-233636106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty