Provider Demographics
NPI:1881332237
Name:FORGEY-CARPENTER, JACQUELLA (LCSW)
Entity type:Individual
Prefix:MISS
First Name:JACQUELLA
Middle Name:
Last Name:FORGEY-CARPENTER
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 1:16149 SW 62ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-5582
Mailing Address - Country:US
Mailing Address - Phone:203-745-6287
Mailing Address - Fax:
Practice Address - Street 1:16149 SW 62ND TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5582
Practice Address - Country:US
Practice Address - Phone:203-745-6287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YM0800X, 104100000X
CT13862101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1881332237Medicaid
CT13862Medicaid