Provider Demographics
NPI:1669720058
Name:TORNOW, JACQUELINE ELAINE (MA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELAINE
Last Name:TORNOW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 N WORTHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-6143
Mailing Address - Country:US
Mailing Address - Phone:386-848-5094
Mailing Address - Fax:
Practice Address - Street 1:804 N WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2709
Practice Address - Country:US
Practice Address - Phone:386-734-7571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070525000Medicaid