Basic Information
| Provider Information | |||||||||
| NPI: | 1366558132 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH CENTER OF JACKSONVILLE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19189 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322459189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047431883 | ||||||||
| FaxNumber: | 9047435109 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 W 20TH ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322541703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046959145 | ||||||||
| FaxNumber: | 9046952465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 01/26/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/29/2014 | ||||||||
| NPIReactivationDate: | 01/02/2015 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SOMMERS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 9047431883 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 283Q00000X | N | Hospitals | Psychiatric Hospital | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 060366002 | 05 | FL | MEDICAID | 060366000 | 05 | FL | MEDICAID |