Basic Information
| Provider Information | |||||||||
| NPI: | 1477687598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | WILLIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322042933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048996300 | ||||||||
| FaxNumber: | 9048996380 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 PARK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322042933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048996300 | ||||||||
| FaxNumber: | 9048996380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | MH5303 | 01 | FL | COMM. BEHAVIORAL HEALTH | OTHER |