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6015 Chester Cir Ste 113 Jacksonville FL 32217-2270 | |
| (904) 853-0739 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 6015 Chester Cir Ste 113, Jacksonville, Florida |
| Authorized Official Name and Position | Javier Sanes-santiago (CEO) |
| Authorized Official Contact | 9043290267 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
6015 Chester Cir Ste 113 Jacksonville FL 32217-2270 Ph: (904) 853-0739 | 6015 Chester Cir Ste 113 Jacksonville FL 32217-2270 Ph: (904) 853-0739 |
| NPI Number | 1740997923 |
|---|---|
| Provider Enumeration Date | 10/28/2022 |
| Last Update Date | 04/01/2023 |
| Certification Date | 04/01/2023 |
| Medicare PECOS PAC ID | 5890135347 |
|---|---|
| Medicare Enrollment ID | O20240430004350 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1740997923 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| 171M00000X | Case Manager/care Coordinator | (* (Not Available)) | Secondary |
| Provider Name | Maryam Archer |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1427639046 PECOS PAC ID: 6901256106 Enrollment ID: I20240102000008 |
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