Healthcare Provider Details

I. General information

NPI: 1336616382
Provider Name (Legal Business Name): ISHMAEL EAVES FARRA MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6639 SOUTHPOINT PKWY STE 108
JACKSONVILLE FL
32216-8042
US

IV. Provider business mailing address

6639 SOUTHPOINT PKWY STE 108
JACKSONVILLE FL
32216-8042
US

V. Phone/Fax

Practice location:
  • Phone: 904-438-7640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: