Provider Demographics
NPI:1336354091
Name:RESNICK, JAQUELYN LISS (PHD)
Entity Type:Individual
Prefix:
First Name:JAQUELYN
Middle Name:LISS
Last Name:RESNICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SW 29TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-9010
Mailing Address - Country:US
Mailing Address - Phone:352-378-8223
Mailing Address - Fax:352-392-8453
Practice Address - Street 1:700 SW 29TH PL
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-9010
Practice Address - Country:US
Practice Address - Phone:352-392-1575
Practice Address - Fax:352-392-8452
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY002780103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling