Provider Demographics
NPI:1528565116
Name:FIELDS, DOREATHA JACKSON (EDD)
Entity Type:Individual
Prefix:
First Name:DOREATHA
Middle Name:JACKSON
Last Name:FIELDS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:DR
Other - First Name:DOREATHA
Other - Middle Name:J
Other - Last Name:FIELDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:250 HAMMOCK RD SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-8848
Mailing Address - Country:US
Mailing Address - Phone:321-543-1420
Mailing Address - Fax:
Practice Address - Street 1:1409 HOAG AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-7311
Practice Address - Country:US
Practice Address - Phone:321-821-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor