Provider Demographics
NPI:1780859728
Name:LEE-JACKSON, MILDRED JEAN (PT)
Entity Type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:JEAN
Last Name:LEE-JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8022
Mailing Address - Country:US
Mailing Address - Phone:850-678-6436
Mailing Address - Fax:
Practice Address - Street 1:178 HOWARD ST
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8022
Practice Address - Country:US
Practice Address - Phone:850-678-6436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0003333174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891638100Medicaid