Provider Demographics
NPI:1568474229
Name:MCMILLON, JADA LANITA
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:LANITA
Last Name:MCMILLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5118 N 56TH ST
Mailing Address - Street 2:SUITE 224
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-5416
Mailing Address - Country:US
Mailing Address - Phone:813-977-7677
Mailing Address - Fax:813-977-5017
Practice Address - Street 1:5118 N 56TH ST
Practice Address - Street 2:SUITE 224
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-5416
Practice Address - Country:US
Practice Address - Phone:813-977-7677
Practice Address - Fax:813-977-5017
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76676800Medicaid