Provider Demographics
NPI:1740767649
Name:JACKSON, CHEVON (MSW)
Entity Type:Individual
Prefix:MS
First Name:CHEVON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 OLIVE TREE CIR
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33413-3052
Mailing Address - Country:US
Mailing Address - Phone:954-326-7776
Mailing Address - Fax:
Practice Address - Street 1:525 NW LAKE WHITNEY PL STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1605
Practice Address - Country:US
Practice Address - Phone:772-337-8164
Practice Address - Fax:772-337-8165
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10018101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health