Provider Demographics
NPI:1538385919
Name:VALDES, JACQUELINE C (PHD)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:C
Last Name:VALDES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:CHEHEBAR
Other - Last Name:VALDES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:406 SW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-3108
Mailing Address - Country:US
Mailing Address - Phone:954-426-1169
Mailing Address - Fax:954-725-5814
Practice Address - Street 1:2214 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-6702
Practice Address - Country:US
Practice Address - Phone:954-426-8840
Practice Address - Fax:954-426-6642
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4945103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59574Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER