Healthcare Provider Details

I. General information

NPI: 1306478797
Provider Name (Legal Business Name): JOHN ELLISON COMMUNITY RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 SAINT AUGUSTINE RD STE 9A
JACKSONVILLE FL
32217-2813
US

IV. Provider business mailing address

6320 SAINT AUGUSTINE RD STE 9A
JACKSONVILLE FL
32217-2813
US

V. Phone/Fax

Practice location:
  • Phone: 904-661-1985
  • Fax: 904-619-0984
Mailing address:
  • Phone: 904-661-1985
  • Fax: 904-619-0984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: TEKESHA ELLISON
Title or Position: VP OF OPERATIONS
Credential:
Phone: 904-888-4634