Provider Demographics
NPI:1215973425
Name:JACKSON, DAWN (PSYD)
Entity type:Individual
Prefix:DR
First Name:DAWN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 W SAMPLE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4077
Mailing Address - Country:US
Mailing Address - Phone:954-320-7881
Mailing Address - Fax:
Practice Address - Street 1:9900 W SAMPLE RD STE 300
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4077
Practice Address - Country:US
Practice Address - Phone:954-320-7881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015925-1103TC0700X
FLPY8115103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02666544Medicaid
NY02666544Medicaid