Provider Demographics
NPI:1124756101
Name:VARGAS, JACQUELINE MARIA (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIA
Last Name:VARGAS
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 1:3564 AVALON PARK EAST BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7365
Mailing Address - Country:US
Mailing Address - Phone:863-256-9604
Mailing Address - Fax:
Practice Address - Street 1:3564 AVALON PARK EAST BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7365
Practice Address - Country:US
Practice Address - Phone:863-256-9604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL185971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty