Provider Demographics
NPI:1356741706
Name:PHILLIPS, JACQUELINE ELISE MARIE (LMHC)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ELISE MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12353 HAMPTON PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-4105
Mailing Address - Country:US
Mailing Address - Phone:813-462-9115
Mailing Address - Fax:727-499-7920
Practice Address - Street 1:12353 HAMPTON PARK BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-4105
Practice Address - Country:US
Practice Address - Phone:813-462-9115
Practice Address - Fax:727-499-7920
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18252101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health