Provider Demographics
NPI:1952985160
Name:MENTOR, JACQUELYN (EDD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:MENTOR
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9310 BARRINGTON OAKS DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:FL
Mailing Address - Zip Code:33527-3758
Mailing Address - Country:US
Mailing Address - Phone:813-684-2304
Mailing Address - Fax:
Practice Address - Street 1:9310 BARRINGTON OAKS DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527-3758
Practice Address - Country:US
Practice Address - Phone:813-684-2304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9344101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health