Provider Demographics
NPI:1750450904
Name:PERTUSIELLO, JACQUELINE ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANN
Last Name:PERTUSIELLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 NW 126TH TER
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-4435
Mailing Address - Country:US
Mailing Address - Phone:954-341-9192
Mailing Address - Fax:
Practice Address - Street 1:19425 SW 58TH MNR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33332-3338
Practice Address - Country:US
Practice Address - Phone:954-392-5689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW45981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical