Provider Demographics
NPI:1023761624
Name:JACKSON, MIKAELA
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
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 1:5212 BRIGHTON SHORE DR
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-3317
Mailing Address - Country:US
Mailing Address - Phone:813-459-4660
Mailing Address - Fax:
Practice Address - Street 1:2688 STONEWOOD PARK LOOP
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-6210
Practice Address - Country:US
Practice Address - Phone:813-481-9662
Practice Address - Fax:813-704-2600
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-22-200280OtherREGISTERED BEHAVIOR THERAPIST