Provider Demographics
NPI:1922564012
Name:JACKSON, CHARMAYNE LATRIECE (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:CHARMAYNE
Middle Name:LATRIECE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 NW 23RD BLVD APT B20
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2926
Mailing Address - Country:US
Mailing Address - Phone:317-698-2713
Mailing Address - Fax:
Practice Address - Street 1:2601 NW 23RD BLVD APT 243
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-5958
Practice Address - Country:US
Practice Address - Phone:317-698-2713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
FLMH22183101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor