Provider Demographics
NPI:1053959023
Name:JACKSON DORMAN, LYNN STEPHANIE (LMHC)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:STEPHANIE
Last Name:JACKSON DORMAN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2407 W CONLEY AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-4762
Mailing Address - Country:US
Mailing Address - Phone:404-293-0395
Mailing Address - Fax:
Practice Address - Street 1:1700 PARK ST N STE 110
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-4300
Practice Address - Country:US
Practice Address - Phone:813-644-2747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional