Basic Information
| Provider Information | |||||||||
| NPI: | 1881636553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOONEYHAM | ||||||||
| FirstName: | SJOUKJE | ||||||||
| MiddleName: | ODETTE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | C.N.M./A.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4425 MERRIMAC AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322101850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043460050 | ||||||||
| FaxNumber: | 9043460080 | ||||||||
| Practice Location | |||||||||
| Address1: | 4425 MERRIMAC AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322101850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043460050 | ||||||||
| FaxNumber: | 9043460080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | ARNP3408202 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 003110725A | 05 | GA | MEDICAID | 3078418 | 05 | FL | MEDICAID |