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12724 Gran Bay Pkwy W Ste 410 Jacksonville FL 32258-9486 | |
| (608) 371-9624 | |
| (239) 232-6100 |
| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 12724 Gran Bay Pkwy W Ste 410, Jacksonville, Florida |
| Authorized Official Name and Position | Emem Williams (CEO) |
| Authorized Official Contact | 6083719624 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
12724 Gran Bay Pkwy W Ste 410 Jacksonville FL 32258-9486 Ph: (608) 371-9624 | 12724 Gran Bay Pkwy W Ste 410 Jacksonville FL 32258-9486 Ph: (608) 371-9624 |
| NPI Number | 1356797567 |
|---|---|
| Provider Enumeration Date | 05/05/2016 |
| Last Update Date | 08/02/2023 |
| Certification Date | 08/02/2023 |
| Medicare PECOS PAC ID | 5496048449 |
|---|---|
| Medicare Enrollment ID | O20240216003781 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1356797567 | NPI | - | NPPES |
| Provider Name | John R Wilson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1093955775 PECOS PAC ID: 5890072276 Enrollment ID: I20170512001239 |
| Provider Name | Emem Williams |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1013377365 PECOS PAC ID: 1052617859 Enrollment ID: I20200303001167 |
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