Provider Demographics
NPI:1700366721
Name:PEART, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PEART
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 1:9820 W HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2384
Mailing Address - Country:US
Mailing Address - Phone:175-442-3363
Mailing Address - Fax:
Practice Address - Street 1:9820 W HEATHER LN
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-2384
Practice Address - Country:US
Practice Address - Phone:754-423-3632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20-0199524Medicaid