Provider Demographics
NPI:1760733398
Name:CLARKE JEMMOTT, JACQUELINE KATHLEEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:KATHLEEN
Last Name:CLARKE JEMMOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 835
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-0835
Mailing Address - Country:US
Mailing Address - Phone:954-274-0507
Mailing Address - Fax:
Practice Address - Street 1:7203 PINE FOREST RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526
Practice Address - Country:US
Practice Address - Phone:954-274-0507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-22
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMCAP010627101YA0400X
FLMT2821101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1760733398Medicaid