Provider Demographics
NPI:1669675369
Name:JACKSON, SANDRA JONES (LCPC, PROV LMHC)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:JONES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCPC, PROV LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-5108
Mailing Address - Country:US
Mailing Address - Phone:772-873-8305
Mailing Address - Fax:772-873-8307
Practice Address - Street 1:560 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5108
Practice Address - Country:US
Practice Address - Phone:772-873-8305
Practice Address - Fax:772-873-8307
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMH 729101YM0800X
MDLC1622101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional