Provider Demographics
NPI:1679145544
Name:BLAQUIERE, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BLAQUIERE
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 1:5050 CRAYTON RD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-2442
Mailing Address - Country:US
Mailing Address - Phone:304-685-7098
Mailing Address - Fax:
Practice Address - Street 1:28410 BONITA XING BLVD UNIT 150
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-3217
Practice Address - Country:US
Practice Address - Phone:239-451-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-24-73004103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician