Provider Demographics
NPI:1952955924
Name:JACKSON, CANDICE S (LMFT)
Entity type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11026 SW 110TH AVE
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34432-5581
Mailing Address - Country:US
Mailing Address - Phone:352-208-1458
Mailing Address - Fax:
Practice Address - Street 1:11026 SW 110TH AVE
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432-5581
Practice Address - Country:US
Practice Address - Phone:352-208-1458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4958106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist