Healthcare Provider Details

I. General information

NPI: 1053660399
Provider Name (Legal Business Name): KIM ANISE JACKSON-MCCALLA M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 TECH BLVD
TAMPA FL
33610
US

IV. Provider business mailing address

1513 E. 31ST AVE
TAMPA FL
33610
US

V. Phone/Fax

Practice location:
  • Phone: 813-635-9765
  • Fax:
Mailing address:
  • Phone: 813-340-2286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: