Provider Demographics
NPI:1356863823
Name:MAPLE, JACQUELINE ANNE (LMHC, MCAP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANNE
Last Name:MAPLE
Suffix:
Gender:F
Credentials:LMHC, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 TOLUCA ST SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-7420
Mailing Address - Country:US
Mailing Address - Phone:321-272-1371
Mailing Address - Fax:
Practice Address - Street 1:827 TOLUCA ST SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-7420
Practice Address - Country:US
Practice Address - Phone:321-272-1371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH14960101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMCAP100566OtherFL CERTIFICATION BOARD
FLMH16368OtherSTATE OF FL DOH