Provider Demographics
NPI:1861441313
Name:FERGUSON, JACQUELYN R (MS)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:R
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4596 LITTLE RIVER LN
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-3123
Mailing Address - Country:US
Mailing Address - Phone:239-693-8111
Mailing Address - Fax:239-693-8111
Practice Address - Street 1:4596 LITTLE RIVER LN
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-3123
Practice Address - Country:US
Practice Address - Phone:239-693-8111
Practice Address - Fax:239-693-8111
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0383101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH0383OtherMHC LICENSE NUMBER