Active NPI
Jeanette Jackson, LCSW
- Clinical Social Worker
- Bristol, FL
National Provider Identifier
1407019797
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- SW6714
- Practice address
- 12422 NW G T Revell Rd
Bristol, FL 32321-3007 - Phone
- (850) 643-4600
- Fax
- (850) 643-2061
- NPI assigned
- Jul 7, 2008
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | SW6714 | FL | Primary |
Addresses
Primary practice location
12422 NW G T Revell Rd
Bristol, FL 32321-3007
Mailing address
12422 NW G T Revell Rd
Bristol, FL 32321-3007
Phone (850) 643-4600
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| SW6714 | FL | MD | Clinical Social Worker |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Keystone DJJ, LLC | Past | Accepting new patients | |
| Bristol Youth Academy | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Psychiatric Residential Treatment Facility
- Bristol, FL
- NPI 1447359435
-
- Counselor
- Bristol, FL
- NPI 1134309438
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1215388800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1215388800000",
"number": "1407019797",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12422 NW G T REVELL RD",
"city": "BRISTOL",
"state": "FL",
"postal_code": "323213007",
"telephone_number": "850-643-4600",
"fax_number": "850-643-2061"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12422 NW G T REVELL RD",
"city": "BRISTOL",
"state": "FL",
"postal_code": "323213007",
"telephone_number": "850-643-4600",
"fax_number": "850-643-2061"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "JEANETTE",
"name_prefix": "Mrs.",
"credential": "LCSW",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2008-07-07",
"last_updated": "2008-07-07",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "FL",
"license": "SW6714",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bristol, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 7, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.