Provider Demographics
NPI:1942717202
Name:JEAN-JACQUES, ADELINE
Entity Type:Individual
Prefix:MS
First Name:ADELINE
Middle Name:
Last Name:JEAN-JACQUES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11166 STONE CREEK ST
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33449-8332
Mailing Address - Country:US
Mailing Address - Phone:561-503-1988
Mailing Address - Fax:
Practice Address - Street 1:11166 STONE CREEK ST
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8332
Practice Address - Country:US
Practice Address - Phone:561-503-1988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003232800Medicaid