Provider Demographics
NPI:1790991214
Name:PEASE, JEAN A (LCSW)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:A
Last Name:PEASE
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 1:1985 ARDEN FOREST PL
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-2304
Mailing Address - Country:US
Mailing Address - Phone:904-333-1996
Mailing Address - Fax:
Practice Address - Street 1:4375 US HIGHWAY 17
Practice Address - Street 2:SUITE 103
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4832
Practice Address - Country:US
Practice Address - Phone:904-269-0886
Practice Address - Fax:904-269-0499
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW74161041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL765924500Medicaid
FLCT531ZMedicare PIN