Provider Demographics
NPI:1659390318
Name:JACKSON-NORMAN, FANITA LAKAYE (LCSW)
Entity Type:Individual
Prefix:
First Name:FANITA
Middle Name:LAKAYE
Last Name:JACKSON-NORMAN
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 1:589 S INDIGO RD
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3197
Mailing Address - Country:US
Mailing Address - Phone:407-463-5500
Mailing Address - Fax:
Practice Address - Street 1:551 NATIONAL HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1495
Practice Address - Country:US
Practice Address - Phone:386-323-7530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00041751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical