Provider Demographics
NPI:1568255230
Name:JACKSON, TYLER (IMT4395)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:IMT4395
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 SHEOAH BLVD APT 36
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-2438
Mailing Address - Country:US
Mailing Address - Phone:407-921-2160
Mailing Address - Fax:
Practice Address - Street 1:1600 E ROBINSON ST STE 250
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5955
Practice Address - Country:US
Practice Address - Phone:407-423-3327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT4395106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist