Provider Demographics
NPI:1972119907
Name:MCEWAN, JACQUELINE MARIE (RBT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:MCEWAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6421 N FLORIDA AVE
Mailing Address - Street 2:SUITE D-1458
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-6007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6421 N FLORIDA AVE
Practice Address - Street 2:SUITE D-1458
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-6007
Practice Address - Country:US
Practice Address - Phone:772-349-6317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-131092106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108082100Medicaid