Basic Information
| Provider Information | |||||||||
| NPI: | 1881980027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKEE | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | GARDNER | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 VETERANS WAY STE A | ||||||||
| Address2: | |||||||||
| City: | VIERA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216373788 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2900 VETERANS WAY | ||||||||
| Address2: | |||||||||
| City: | VIERA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2138069706 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 12374 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1841281805 | 01 | KS | CENTER NPI | OTHER |