Provider Demographics
NPI:1285853481
Name:JACKSON, JOHN EDWARD (BS MS,LMHC,CAP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWARD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BS MS,LMHC,CAP
Other - Prefix:
Other - First Name:TERREL
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6022 NW 91ST WAY
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-4100
Mailing Address - Country:US
Mailing Address - Phone:954-720-5523
Mailing Address - Fax:
Practice Address - Street 1:1851 NW 123RD AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3825
Practice Address - Country:US
Practice Address - Phone:954-432-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3282101YA0400X
FLMH8379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health