Provider Demographics
NPI:1093104234
Name:JACKSON, KATINA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATINA
Middle Name:
Last Name:JACKSON
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 1:8050 BLUE STAR HWY
Mailing Address - Street 2:
Mailing Address - City:CHATTAHOOCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:32324-2934
Mailing Address - Country:US
Mailing Address - Phone:850-273-2322
Mailing Address - Fax:
Practice Address - Street 1:1607 SAINT JAMES CT
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5352
Practice Address - Country:US
Practice Address - Phone:850-878-0191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 106021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical