Provider Demographics
NPI:1952909772
Name:JACKSON, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
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 1:3401 N LAKEVIEW DR APT 715
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1356
Mailing Address - Country:US
Mailing Address - Phone:802-345-0957
Mailing Address - Fax:
Practice Address - Street 1:6951 PISTOL RANGE RD STE 101
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-9642
Practice Address - Country:US
Practice Address - Phone:813-696-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician