Healthcare Provider Details

I. General information

NPI: 1356330765
Provider Name (Legal Business Name): SANDRA JACKSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA MELCHIONNE LMHC

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 SAN SEBASTIAN VW STE 4201
ST AUGUSTINE FL
32084-8684
US

IV. Provider business mailing address

150 MAGNOLIA AVE
DAYTONA BEACH FL
32114-4304
US

V. Phone/Fax

Practice location:
  • Phone: 800-539-4228
  • Fax:
Mailing address:
  • Phone: 800-539-4228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH8391
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMH8391
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: