MEDICARE: THERESA COUNCIL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251K00000X	Public Health or Welfare Agency
2	251V00000X	Voluntary or Charitable Agency
3	261QC1500X	Community Health Clinic/Center
4	101Y00000X	Counselor

General Provider Information

NPI Number	:	1700369857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERESA COUNCIL LLC

Provider Business Mailing Address
First Line	:	2815 MELSON AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32254-1853
Country	:	US
Telephone Number	:	904-355-6864
Fax Number	:

Provider Business Practice Location Address
First Line	:	2815 MELSON AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32254-1853
Country	:	US
Telephone Number	:	904-355-6864
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	THERESA COUNCIL
Credential	:
Telephone Number	:	904-355-6864

Provider Enumeration Date	:	09/13/2018
Last Update Date	:	06/30/2019

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Directions to “THERESA COUNCIL LLC ” Practice Location

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