Basic Information
| Provider Information | |||||||||
| NPI: | 1528197654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIX | ||||||||
| FirstName: | JEANINE | ||||||||
| MiddleName: | DONALDSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DONALDSON | ||||||||
| OtherFirstName: | JEANINE | ||||||||
| OtherMiddleName: | YVONNE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D,LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544864005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1957 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330205021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549212600 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 10/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | SW1166 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | SW1166 | FL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 767418000 | 05 | FL | MEDICAID |