Provider Demographics
NPI:1801338413
Name:MCMILLAN, JACQUELYN (PHD, LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 OLD WOODVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32327-0533
Mailing Address - Country:US
Mailing Address - Phone:850-421-1123
Mailing Address - Fax:
Practice Address - Street 1:720 OLD WOODVILLE RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-0533
Practice Address - Country:US
Practice Address - Phone:850-421-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW139591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW13959Medicare PIN