Provider Demographics
NPI:1689327058
Name:COLE, JACQUELINE (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9190
Mailing Address - Fax:239-343-9193
Practice Address - Street 1:12550 NEW BRITTANY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3655
Practice Address - Country:US
Practice Address - Phone:239-343-9180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW19265101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116060500Medicaid