Provider Demographics
NPI:1497200307
Name:SIMON, JACQUELINE DEBORAH (APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DEBORAH
Last Name:SIMON
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2091 NE 36TH ST UNIT 51838
Mailing Address - Street 2:
Mailing Address - City:LIGHTHOUSE POINT
Mailing Address - State:FL
Mailing Address - Zip Code:33074-2606
Mailing Address - Country:US
Mailing Address - Phone:954-540-6547
Mailing Address - Fax:
Practice Address - Street 1:2382 NE 29TH ST
Practice Address - Street 2:
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-8131
Practice Address - Country:US
Practice Address - Phone:954-540-6547
Practice Address - Fax:949-695-4648
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9328821363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101264100Medicaid