Provider Demographics
NPI:1629625843
Name:GRANDA, JACQUELYN MICHELLE (LMHC, NCC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MICHELLE
Last Name:GRANDA
Suffix:
Gender:F
Credentials:LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8267 VIA LEONESSA
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-2220
Mailing Address - Country:US
Mailing Address - Phone:561-902-8317
Mailing Address - Fax:
Practice Address - Street 1:21301 POWERLINE RD STE 304
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-2391
Practice Address - Country:US
Practice Address - Phone:561-902-8317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17038101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health