Provider Demographics
NPI:1073914230
Name:WATSON-JACK, TAI-ISHA (LCSW)
Entity Type:Individual
Prefix:
First Name:TAI-ISHA
Middle Name:
Last Name:WATSON-JACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3027 SAN DIEGO RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3691
Mailing Address - Country:US
Mailing Address - Phone:904-568-8215
Mailing Address - Fax:
Practice Address - Street 1:3027 SAN DIEGO RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3691
Practice Address - Country:US
Practice Address - Phone:904-568-8215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03505424Medicaid
FLSW18676OtherSTATE LICENSE