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Provider Information for 1922210210


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VIVIAN ANN JACKSON LMHC


Sex: Female

NPI: 1922210210
Last Updated: 2022-03-23
Certification Date: 2022-03-23

Details

NameValue
NPI1922210210
Enumeration Date2007-05-07
NPI TypeNPI-1 Individual
Sole ProprietorNO
StatusActive
Mailing Address 4300 SW 13TH ST
GAINESVILLE, FL 32608-4006
United States

Phone: 352-374-5600 | Fax:352-224-2741
 
Primary Practice Address 945 GRAND ST
STARKE, FL 32091-1821
United States

Phone: 352-374-5600 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 101YM0800X - Counselor - Mental HealthFLMH17142