Provider Demographics
NPI:1396014635
Name:LAWSON, ALEXIS
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:LAWSON
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 1:3332 EMAN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5646
Mailing Address - Country:US
Mailing Address - Phone:904-226-9633
Mailing Address - Fax:
Practice Address - Street 1:6789 SOUTHPOINT PKWY STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8205
Practice Address - Country:US
Practice Address - Phone:904-226-9633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-43876103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017936900Medicaid