Provider Demographics
NPI:1700448222
Name:FREY, JACQUELINE MARIE (RCSWI, MSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:FREY
Suffix:
Gender:F
Credentials:RCSWI, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 SKATE RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:804 3RD ST STE A-B
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-5040
Practice Address - Country:US
Practice Address - Phone:904-834-0529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-04
Last Update Date:2019-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW12945101Y00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor