Healthcare Provider Details

I. General information

NPI: 1982374161
Provider Name (Legal Business Name): JULIA ELAINE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date: 07/22/2024
Reactivation Date: 08/01/2024

III. Provider practice location address

48 COUNTRY FERN DR
ST AUGUSTINE FL
32092-3383
US

IV. Provider business mailing address

48 COUNTRY FERN DR
ST AUGUSTINE FL
32092-3383
US

V. Phone/Fax

Practice location:
  • Phone: 561-301-4394
  • Fax:
Mailing address:
  • Phone: 561-301-4394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number24048
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: