Provider Demographics
NPI:1790846616
Name:COLUNGA, JACQUELINE SUE (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUE
Last Name:COLUNGA
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 1:5128 27TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-5414
Mailing Address - Country:US
Mailing Address - Phone:727-327-9046
Mailing Address - Fax:
Practice Address - Street 1:5128 27TH AVE S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-5414
Practice Address - Country:US
Practice Address - Phone:727-327-9046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW8486171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator