Provider Demographics
NPI:1811299779
Name:TAYLOR, JESSE OWEN (LCSW)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:OWEN
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 BAYSHORE BLVD
Mailing Address - Street 2:UNIT # 1803
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-7351
Mailing Address - Country:US
Mailing Address - Phone:813-731-9552
Mailing Address - Fax:
Practice Address - Street 1:1536 NORTH JEFFERSON STREET
Practice Address - Street 2:VA JACKSONVILLE OPC MENTAL HEALTH
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209
Practice Address - Country:US
Practice Address - Phone:707-995-7201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-29
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW97311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical