Healthcare Provider Details

I. General information

NPI: 1578104220
Provider Name (Legal Business Name): JENNA MICHELSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1536 N JEFFERSON ST
JACKSONVILLE FL
32209-6525
US

IV. Provider business mailing address

1536 N JEFFERSON ST
JACKSONVILLE FL
32209-6525
US

V. Phone/Fax

Practice location:
  • Phone: 904-493-7744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1142006
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.250692
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904018629
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW19221
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: