Provider Demographics
NPI:1417377060
Name:NIXON, JESSICA (M ED)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:NIXON
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5807 N ATLANTIC AVE APT 625
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-3969
Mailing Address - Country:US
Mailing Address - Phone:321-458-5107
Mailing Address - Fax:
Practice Address - Street 1:5807 N ATLANTIC AVE APT 625
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-3969
Practice Address - Country:US
Practice Address - Phone:321-458-5107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1107124101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool