Healthcare Provider Details

I. General information

NPI: 1811327877
Provider Name (Legal Business Name): MONICA JACKSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 LEE RD STE 200
WINTER PARK FL
32789-2106
US

IV. Provider business mailing address

3224 CHAMBERLAIN ST
DELTONA FL
32738-2505
US

V. Phone/Fax

Practice location:
  • Phone: 407-622-6121
  • Fax:
Mailing address:
  • Phone: 321-277-7688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 11827
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: