Provider Demographics
NPI:1396242558
Name:DUBOIS, JACQUELINE
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7547 SAND LAKE POINTE LOOP
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-7219
Mailing Address - Country:US
Mailing Address - Phone:941-465-2299
Mailing Address - Fax:
Practice Address - Street 1:7547 SAND LAKE POINTE LOOP
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-7219
Practice Address - Country:US
Practice Address - Phone:941-465-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD120-420-89-513-0Medicaid