Provider Demographics
NPI:1629385422
Name:LANSDALE, JACQUELYN COURTNEY (MA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:COURTNEY
Last Name:LANSDALE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:JACKIE
Other - Middle Name:LANSDALE
Other - Last Name:MCLEISH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:175 MIDDLE ST UNIT 1201
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3625
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:6951 PISTOL RANGE RD STE 101
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-9613
Practice Address - Country:US
Practice Address - Phone:813-814-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2017-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
FL1-13-13230103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171W00000XOther Service ProvidersContractor