Provider Demographics
NPI:1740631738
Name:HAROLD JACKSON, TERRA
Entity type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:HAROLD 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 1:3890 DUNN AVE
Mailing Address - Street 2:SUITE 1104
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-6428
Mailing Address - Country:US
Mailing Address - Phone:904-723-6049
Mailing Address - Fax:904-723-5049
Practice Address - Street 1:3890 DUNN AVE
Practice Address - Street 2:SUITE 1104
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6428
Practice Address - Country:US
Practice Address - Phone:904-723-6049
Practice Address - Fax:904-723-5049
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No104100000XBehavioral Health & Social Service ProvidersSocial Worker