Provider Demographics
NPI:1619233566
Name:HAWKINS-JACK, RUBY LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:LISA
Last Name:HAWKINS-JACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 JAMAICA WAY
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3831
Mailing Address - Country:US
Mailing Address - Phone:850-279-3045
Mailing Address - Fax:850-279-3045
Practice Address - Street 1:358 JAMAICA WAY
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-3831
Practice Address - Country:US
Practice Address - Phone:850-279-3045
Practice Address - Fax:850-279-3045
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010818841041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool