Provider Demographics
NPI:1104004746
Name:JACKSON, CANDIS L (LMHC)
Entity type:Individual
Prefix:MS
First Name:CANDIS
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 512139
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33951-2139
Mailing Address - Country:US
Mailing Address - Phone:941-625-5895
Mailing Address - Fax:941-625-1047
Practice Address - Street 1:4161 TAMIAMI TRL STE 304D
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9254
Practice Address - Country:US
Practice Address - Phone:941-625-5895
Practice Address - Fax:941-625-1047
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4441101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116480500Medicaid