Provider Demographics
NPI:1053741926
Name:JACKSON, LANCE (LMHC)
Entity type:Individual
Prefix:MR
First Name:LANCE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 NE 103RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2432
Mailing Address - Country:US
Mailing Address - Phone:305-763-9565
Mailing Address - Fax:
Practice Address - Street 1:7360 CORAL WAY
Practice Address - Street 2:SUITE #23B
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1498
Practice Address - Country:US
Practice Address - Phone:305-763-9565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11229101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health