Healthcare Provider Details

I. General information

NPI: 1558068379
Provider Name (Legal Business Name): GEORGE JAMES MENDES M.A, M.DIV., D.MIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4375 US HIGHWAY 17 STE 103
FLEMING ISLAND FL
32003-4832
US

IV. Provider business mailing address

2646 KERMIT CT
ORANGE PARK FL
32065-7682
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-0886
  • Fax:
Mailing address:
  • Phone: 619-565-9650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21871
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: