Provider Demographics
NPI:1346984234
Name:COOMBS, JACKLYN
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:COOMBS
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 1:1673 MASON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5516
Mailing Address - Country:US
Mailing Address - Phone:386-873-0365
Mailing Address - Fax:
Practice Address - Street 1:1673 MASON AVE STE 100
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5516
Practice Address - Country:US
Practice Address - Phone:386-873-0365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker