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4600 Beach Blvd. Jacksonville FL 32207 | |
| (904) 346-5100 | |
| (904) 346-5111 |
| Full Name | |
|---|---|
| Speciality | Counselor - Mental Health |
| Location | 4600 Beach Blvd., Jacksonville, Florida |
| Authorized Official Name and Position | Stella Johnson (CHIEF EXECUTIVE OFFICE) |
| Authorized Official Contact | 9043465100 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
4600 Beach Blvd. Jacksonville FL 32207 Ph: (904) 346-5100 | 4600 Beach Blvd. Jacksonville FL 32207 Ph: (904) 346-5100 |
| NPI Number | 1295769602 |
|---|---|
| Provider Enumeration Date | 07/10/2006 |
| Last Update Date | 08/09/2021 |
| Certification Date | 08/09/2021 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1295769602 | NPI | - | NPPES |
| 060135700 | Medicaid | FL | |
| 887343700 | Medicaid | FL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| 103T00000X | Psychologist | (* (Not Available)) | Secondary |
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