Provider Demographics
NPI:1780329698
Name:SMALL DARVILLE, JACQUELINE PARTHENIA
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:PARTHENIA
Last Name:SMALL DARVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 BREVARD AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7849
Mailing Address - Country:US
Mailing Address - Phone:321-433-1111
Mailing Address - Fax:
Practice Address - Street 1:640 BREVARD AVE STE 104
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7849
Practice Address - Country:US
Practice Address - Phone:321-433-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH21892101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty