Provider Demographics
NPI:1265519474
Name:HARDY, JACQUELYN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:
Last Name:HARDY
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 1:4374 GRAN MEADOWS LN N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1316
Mailing Address - Country:US
Mailing Address - Phone:904-673-5726
Mailing Address - Fax:904-821-6715
Practice Address - Street 1:4374 GRAN MEADOWS LN N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-1316
Practice Address - Country:US
Practice Address - Phone:904-673-5726
Practice Address - Fax:904-821-6715
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW27831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL762572300Medicaid