1285131680 NPI number — MRS. JACQUELINE ANNE PITTMAN LCSW

Table of content: MRS. JACQUELINE ANNE PITTMAN LCSW (NPI 1285131680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285131680 NPI number — MRS. JACQUELINE ANNE PITTMAN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PITTMAN
Provider First Name:
JACQUELINE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285131680
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3715 MAHOGANY BEND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34114-6424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-980-1431
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MONARCH WELLNESS, LLC
Provider Second Line Business Practice Location Address:
12264 TAMIAMI TRAIL EAST, SUITE 202
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-231-3208
Provider Business Practice Location Address Fax Number:
239-228-5965
Provider Enumeration Date:
04/11/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW13197 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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