Provider Demographics
NPI:1548604226
Name:JACKSON, CHARLIE (RMHCI)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33831-1559
Mailing Address - Country:US
Mailing Address - Phone:863-519-0575
Mailing Address - Fax:863-582-9251
Practice Address - Street 1:1831 N CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5902
Practice Address - Country:US
Practice Address - Phone:863-519-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
FLIMH16970101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator