Provider Demographics
NPI:1801125638
Name:JACKSON, KIMBERLY S (MSW)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:S
Other - Last Name:HARVEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:841 JIMMY ANN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4583
Mailing Address - Country:US
Mailing Address - Phone:386-425-3953
Mailing Address - Fax:386-258-4912
Practice Address - Street 1:841 JIMMY ANN DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-4583
Practice Address - Country:US
Practice Address - Phone:386-425-3953
Practice Address - Fax:386-258-4912
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW 3000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker