Provider Demographics
NPI:1982374161
Name:JACKSON, JULIA ELAINE
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:ELAINE
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 1:48 COUNTRY FERN DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3383
Mailing Address - Country:US
Mailing Address - Phone:561-301-4394
Mailing Address - Fax:
Practice Address - Street 1:48 COUNTRY FERN DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3383
Practice Address - Country:US
Practice Address - Phone:561-301-4394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2024-08-14
Deactivation Date:2024-07-22
Deactivation Code:
Reactivation Date:2024-08-01
Provider Licenses
StateLicense IDTaxonomies
FL24048101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health