Provider Demographics
NPI:1558789917
Name:JACKSON, NELDA (MA, LMHC,CAP)
Entity Type:Individual
Prefix:
First Name:NELDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA, LMHC,CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 EDITH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815-1216
Mailing Address - Country:US
Mailing Address - Phone:863-533-5860
Mailing Address - Fax:863-519-6983
Practice Address - Street 1:2725 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-8872
Practice Address - Country:US
Practice Address - Phone:863-533-5860
Practice Address - Fax:863-519-6983
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11378101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health