Provider Demographics
NPI:1407129471
Name:RUCH, JACQUELYN J (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:J
Last Name:RUCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11519 SWEETGRASS DR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-2522
Mailing Address - Country:US
Mailing Address - Phone:815-243-8332
Mailing Address - Fax:
Practice Address - Street 1:3205 SOUTHGATE CIR STE 19
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5514
Practice Address - Country:US
Practice Address - Phone:815-243-8332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490150731041C0700X
FLSW157701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149015073OtherLICENSED CLINICAL SOCIAL WORKER
1407129471OtherNPI
IL375792007Medicare PIN