Basic Information
| Provider Information | |||||||||
| NPI: | 1356775787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRANCHE | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3381 PHILLIS BLVD | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295771560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434770177 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10000 BAY PINES BLVD | ||||||||
| Address2: | 1E241C - OEF/OIF/OND | ||||||||
| City: | BAY PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337448200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273986661 | ||||||||
| FaxNumber: | 7273989339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Q1-0001124 | DE | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | SW13898 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.