Provider Demographics
NPI:1285205146
Name:BECKHAM, JALISA B (MSW)
Entity Type:Individual
Prefix:
First Name:JALISA
Middle Name:B
Last Name:BECKHAM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 AKRON OAKS DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-4273
Mailing Address - Country:US
Mailing Address - Phone:904-318-8756
Mailing Address - Fax:
Practice Address - Street 1:1340 AKRON OAKS DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-4273
Practice Address - Country:US
Practice Address - Phone:904-318-8756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW160201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical