Provider Demographics
NPI:1598740896
Name:RITA, JACQUELINE (LMHC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:RITA
Suffix:
Gender:
Credentials:LMHC
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:RITA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:1225 RUTHBERN RD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5961
Mailing Address - Country:US
Mailing Address - Phone:401-486-6081
Mailing Address - Fax:386-401-2414
Practice Address - Street 1:211 E INTERNATIONAL SPEEDWAY BLVD STE 107
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-4662
Practice Address - Country:US
Practice Address - Phone:401-486-6081
Practice Address - Fax:386-401-2414
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11788101YM0800X
RI00222101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI27972-1OtherBLUE CROSS
RI412090OtherBLUE CHIP
RIJR36967Medicaid