Provider Demographics
NPI:1558008789
Name:JACKSON, LAWANDA BEVEL (APRN)
Entity type:Individual
Prefix:
First Name:LAWANDA
Middle Name:BEVEL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13575 58TH ST N STE 200
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3739
Mailing Address - Country:US
Mailing Address - Phone:813-563-1465
Mailing Address - Fax:813-336-8426
Practice Address - Street 1:13575 58TH ST N STE 200
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3739
Practice Address - Country:US
Practice Address - Phone:813-563-1465
Practice Address - Fax:813-336-8426
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9365258363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty