Provider Demographics
NPI:1316576937
Name:JACKSON, LAVONNE
Entity Type:Individual
Prefix:
First Name:LAVONNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7215
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33758-7215
Mailing Address - Country:US
Mailing Address - Phone:757-769-9056
Mailing Address - Fax:
Practice Address - Street 1:622 S BETTY LN APT 2
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-6080
Practice Address - Country:US
Practice Address - Phone:757-769-9056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18659101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18659OtherREGISTER MENTAL HEALTH COUNSELOR INTER