Provider Demographics
NPI:1952828790
Name:LIFESPAN PSYCHIATRIC CARE
Entity Type:Organization
Organization Name:LIFESPAN PSYCHIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, ARNP
Authorized Official - Phone:561-307-7745
Mailing Address - Street 1:701 S OLIVE AVE APT 407
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-6195
Mailing Address - Country:US
Mailing Address - Phone:561-307-7745
Mailing Address - Fax:
Practice Address - Street 1:4800 LINTON BLVD STE D502A
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-6593
Practice Address - Country:US
Practice Address - Phone:561-808-7205
Practice Address - Fax:561-584-6804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9294269363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty