Provider Demographics
NPI:1720375462
Name:RUIZ, JACQUELYN (MSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:
Last Name:RUIZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5545 NW CORDREY ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3925
Mailing Address - Country:US
Mailing Address - Phone:917-846-4696
Mailing Address - Fax:
Practice Address - Street 1:2814 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-8120
Practice Address - Country:US
Practice Address - Phone:772-489-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2015-06-07
Deactivation Date:2015-02-23
Deactivation Code:
Reactivation Date:2015-05-28
Provider Licenses
StateLicense IDTaxonomies
NY082404-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker