Provider Demographics
NPI:1780736983
Name:VIOLA, JACQUELINE BOUDREAU (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BOUDREAU
Last Name:VIOLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12058 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 703
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8666
Mailing Address - Country:US
Mailing Address - Phone:904-260-0454
Mailing Address - Fax:904-260-0044
Practice Address - Street 1:12058 SAN JOSE BLVD
Practice Address - Street 2:SUITE 703
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8666
Practice Address - Country:US
Practice Address - Phone:904-260-0454
Practice Address - Fax:904-260-0044
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW74101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ117EOtherBLUE CROSS BLUE SHIELD
FLZ117DOtherBLUE CROSS BLUE SHIELD