Provider Demographics
NPI:1952837478
Name:DRBEV MENTAL HEALTH COUNSELING LLC
Entity Type:Organization
Organization Name:DRBEV MENTAL HEALTH COUNSELING LLC
Other - Org Name:BEVERLY JACKSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:813-434-3705
Mailing Address - Street 1:9800 4TH ST N
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2417
Mailing Address - Country:US
Mailing Address - Phone:203-695-3015
Mailing Address - Fax:
Practice Address - Street 1:9800 4TH ST N
Practice Address - Street 2:SUITE 200
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-2417
Practice Address - Country:US
Practice Address - Phone:203-695-3015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009977500Medicaid