Provider Demographics
NPI:1053660399
Name:JACKSON-MCCALLA, KIM ANISE (MS)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ANISE
Last Name:JACKSON-MCCALLA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 E. 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610
Mailing Address - Country:US
Mailing Address - Phone:813-340-2286
Mailing Address - Fax:
Practice Address - Street 1:1412 TECH BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610
Practice Address - Country:US
Practice Address - Phone:813-635-9765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health