Provider Demographics
NPI:1619968716
Name:SACKLOW, FRED (LCSW)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:
Last Name:SACKLOW
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6950 PHILIPS HWY STE 11
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6082
Mailing Address - Country:US
Mailing Address - Phone:904-239-3677
Mailing Address - Fax:904-239-3278
Practice Address - Street 1:6950 PHILIPS HWY STE 11
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-239-3677
Practice Address - Fax:904-866-4029
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-30
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR02529-11041C0700X
FLSW145961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical