Healthcare Provider Details

I. General information

NPI: 1922210210
Provider Name (Legal Business Name): VIVIAN ANN JACKSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 GRAND ST
STARKE FL
32091-1821
US

IV. Provider business mailing address

4300 SW 13TH ST
GAINESVILLE FL
32608-4006
US

V. Phone/Fax

Practice location:
  • Phone: 352-374-5600
  • Fax:
Mailing address:
  • Phone: 352-374-5600
  • Fax: 352-224-2741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH17142
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: