Provider Demographics
NPI:1407477573
Name:ROYSTER, JACQUELINE
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:ROYSTER
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 1:2692 WHISPERING TRAILS DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-1843
Mailing Address - Country:US
Mailing Address - Phone:863-875-9980
Mailing Address - Fax:
Practice Address - Street 1:828 AVENUE N SW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3846
Practice Address - Country:US
Practice Address - Phone:407-789-4619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-115425106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician