Provider Demographics
NPI:1528197654
Name:NIX, JEANINE DONALDSON (PHD LCSW)
Entity Type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:DONALDSON
Last Name:NIX
Suffix:
Gender:F
Credentials:PHD LCSW
Other - Prefix:DR
Other - First Name:JEANINE
Other - Middle Name:YVONNE
Other - Last Name:DONALDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD,LCSW
Mailing Address - Street 1:4740 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5839
Mailing Address - Country:US
Mailing Address - Phone:954-486-4005
Mailing Address - Fax:
Practice Address - Street 1:1957 JACKSON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-5021
Practice Address - Country:US
Practice Address - Phone:954-921-2600
Practice Address - Fax:954-497-3857
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW1166101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767418000Medicaid