Provider Demographics
NPI:1750467833
Name:THOMAS, NANCY JACKSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:JACKSON
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 SWILCAN BRIDGE LN S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-5620
Mailing Address - Country:US
Mailing Address - Phone:904-280-8555
Mailing Address - Fax:904-280-8562
Practice Address - Street 1:13000 SAWGRASS VILLAGE CIR STE 11
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-3078
Practice Address - Country:US
Practice Address - Phone:904-280-8555
Practice Address - Fax:904-280-8562
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003951103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS29533Medicare UPIN
FL73159AMedicare ID - Type Unspecified