Healthcare Provider Details

I. General information

NPI: 1285549733
Provider Name (Legal Business Name): JACKSON GUNTHER BALDWIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S KENTUCKY AVE STE 240
LAKELAND FL
33801-5093
US

IV. Provider business mailing address

1515 BIG OAKS DR APT 305
LAKELAND FL
33810-0818
US

V. Phone/Fax

Practice location:
  • Phone: 863-272-9137
  • Fax:
Mailing address:
  • Phone: 815-685-8579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23573
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: