Provider Demographics
NPI:1245840495
Name:JERNIGAN, ROBERT M JR (MA CAP)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:M
Last Name:JERNIGAN
Suffix:JR
Gender:M
Credentials:MA CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 ESPLANADE AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5647
Mailing Address - Country:US
Mailing Address - Phone:772-672-0412
Mailing Address - Fax:
Practice Address - Street 1:820 37TH PL
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6562
Practice Address - Country:US
Practice Address - Phone:772-569-9788
Practice Address - Fax:772-569-2088
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH19742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health