MEDICARE: THERESA G COUNCIL

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver		FL
2	172V00000X	Community Health Worker		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770075509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA G COUNCIL

Provider Business Mailing Address
First Line	:	2815 MELSON AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32254-1853
Country	:	US
Telephone Number	:	904-570-9418
Fax Number	:	904-570-9418

Provider Business Practice Location Address
First Line	:	2815 MELSON AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32254-1853
Country	:	US
Telephone Number	:	904-570-9418
Fax Number	:	904-570-9418

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2018
Last Update Date	:	06/11/2019

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Directions to “ THERESA G COUNCIL ” Practice Location

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