Provider Demographics
NPI:1104458496
Name:JACKSON, PATRICIA A
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10252 S HWY 441
Mailing Address - Street 2:UNIT 3
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420
Mailing Address - Country:US
Mailing Address - Phone:352-559-2539
Mailing Address - Fax:
Practice Address - Street 1:10252 S HWY 441
Practice Address - Street 2:UNIT 3
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420
Practice Address - Country:US
Practice Address - Phone:352-559-2539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician