Healthcare Provider Details

I. General information

NPI: 1053243402
Provider Name (Legal Business Name): REAGAN LAUREN JACKSO9N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9281 NW 57TH ST APT 303
TAMARAC FL
33351-4376
US

IV. Provider business mailing address

9281 NW 57TH ST APT 303
TAMARAC FL
33351-4376
US

V. Phone/Fax

Practice location:
  • Phone: 757-570-2182
  • Fax:
Mailing address:
  • Phone: 757-570-2182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH28477
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: