Provider Demographics
NPI:1740001544
Name:JACKSON, FANTASHA (MSW)
Entity type:Individual
Prefix:MS
First Name:FANTASHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 MCNAIR RD
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-3669
Mailing Address - Country:US
Mailing Address - Phone:850-570-7023
Mailing Address - Fax:
Practice Address - Street 1:280 MCNAIR RD
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-3669
Practice Address - Country:US
Practice Address - Phone:850-570-7023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker