Provider Demographics
NPI:1720734478
Name:STEWART JACKSON, FELICIA GUINEVERE
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:GUINEVERE
Last Name:STEWART 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 1:4085 NE 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34479-8612
Mailing Address - Country:US
Mailing Address - Phone:352-216-2586
Mailing Address - Fax:
Practice Address - Street 1:4085 NE 19TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34479-8612
Practice Address - Country:US
Practice Address - Phone:352-216-2586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4295106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist