Provider Demographics
NPI:1366157224
Name:LARA, JACKELINE LAURA (LMHC)
Entity type:Individual
Prefix:MISS
First Name:JACKELINE
Middle Name:LAURA
Last Name:LARA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28934 SLEEPY BEAR LN
Mailing Address - Street 2:
Mailing Address - City:SORRENTO
Mailing Address - State:FL
Mailing Address - Zip Code:32776-9529
Mailing Address - Country:US
Mailing Address - Phone:786-294-3186
Mailing Address - Fax:
Practice Address - Street 1:440 ROYELLOU LN STE 207
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-5520
Practice Address - Country:US
Practice Address - Phone:786-294-3186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21252101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health