Individual
JON WALLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LMHC
Contact information
Practice address
4800 W COMMERCIAL BLVD, TAMARAC, FL 33319-2879
(954) 300-3244
Mailing address
925 INTRACOASTAL DR APT 8, FORT LAUDERDALE, FL 33304-3688
(352) 246-4027
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
MH12508
FL
Other
Enumeration date
08/12/2019
Last updated
08/12/2019
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