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4417 Beach Blvd Ste 101 Jacksonville FL 32207-4728 | |
| (904) 551-4953 | |
| (904) 212-2366 |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 4417 Beach Blvd Ste 101, Jacksonville, Florida |
| Authorized Official Name and Position | Meleecia Tucker (CLINICAL DIRECTOR) |
| Authorized Official Contact | 9045364415 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4417 Beach Blvd Ste 101 Jacksonville FL 32207-4728 Ph: (904) 536-4415 | 4417 Beach Blvd Ste 101 Jacksonville FL 32207-4728 Ph: (904) 551-4953 |
| NPI Number | 1699319491 |
|---|---|
| Provider Enumeration Date | 11/05/2019 |
| Last Update Date | 12/04/2023 |
| Certification Date | 12/04/2023 |
| Medicare PECOS PAC ID | 4486062791 |
|---|---|
| Medicare Enrollment ID | O20210426000750 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1699319491 | NPI | - | NPPES |
| 1699319491 | Medicaid | FL |
| Provider Name | Sanjae E Edwards |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1427379585 PECOS PAC ID: 3274941588 Enrollment ID: I20210426000827 |
| Provider Name | Meleecia Dunklin Tucker |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1043632102 PECOS PAC ID: 2567870876 Enrollment ID: I20231117001845 |
| Provider Name | Gabriel Speed |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1437924198 PECOS PAC ID: 1850744434 Enrollment ID: I20240131000095 |
| Provider Name | Deidra D Davis |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1821867425 PECOS PAC ID: 6406295047 Enrollment ID: I20240416002509 |
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