Provider Demographics
NPI:1356330765
Name:JACKSON, SANDRA (LMHC)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:MELCHIONNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:150 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-4304
Mailing Address - Country:US
Mailing Address - Phone:800-539-4228
Mailing Address - Fax:
Practice Address - Street 1:1880 SAN SEBASTIAN VW STE 4201
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-8684
Practice Address - Country:US
Practice Address - Phone:800-539-4228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8391101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767122900Medicaid
FLZ089AOtherBCBS