Provider Demographics
NPI:1467955567
Name:JACKSON, KANDI (LCSW, CCM)
Entity Type:Individual
Prefix:
First Name:KANDI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5836 COPPER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-7334
Mailing Address - Country:US
Mailing Address - Phone:904-710-0625
Mailing Address - Fax:
Practice Address - Street 1:10852 LEM TURNER RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4566
Practice Address - Country:US
Practice Address - Phone:904-710-0625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2024-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
4207813171M00000X
FLSW113391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator