Provider Demographics
NPI:1770788952
Name:FLECK-JACKSON, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FLECK-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 1:4334 BEAUMARIS DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-7780
Mailing Address - Country:US
Mailing Address - Phone:813-500-4303
Mailing Address - Fax:
Practice Address - Street 1:4334 BEAUMARIS DR
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-7780
Practice Address - Country:US
Practice Address - Phone:813-500-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist