Provider Demographics
NPI:1649864885
Name:JACKSON, ANTIONETTE MARIE
Entity type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N CHARLES WILLIS DR
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:FL
Mailing Address - Zip Code:32343-4293
Mailing Address - Country:US
Mailing Address - Phone:850-694-7555
Mailing Address - Fax:
Practice Address - Street 1:110 MELALEUCA DR
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-4963
Practice Address - Country:US
Practice Address - Phone:850-617-9167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional