=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013364132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEATHER JACKSON, MS, LMHC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2016
-----------------------------------------------------
Last Update Date | 05/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 256 CARSON OAKS LN
-----------------------------------------------------
City | SANTA ROSA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32459-7149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-974-1793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 256 CARSON OAKS LN
-----------------------------------------------------
City | SANTA ROSA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32459-7149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HEATHER JACKSON
-----------------------------------------------------
Credential | LHMC
-----------------------------------------------------
Telephone | 850-974-1793
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | MH 14095
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------