Provider Demographics
NPI:1669533857
Name:MALONEY, JACK (LCSW- CAP)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MALONEY
Suffix:
Gender:M
Credentials:LCSW- CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 GRAND MEADOWS BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-2948
Mailing Address - Country:US
Mailing Address - Phone:321-305-2766
Mailing Address - Fax:
Practice Address - Street 1:4125 GRAND MEADOWS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-2948
Practice Address - Country:US
Practice Address - Phone:321-305-2766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 90201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical