Healthcare Provider Details

I. General information

NPI: 1093256158
Provider Name (Legal Business Name): GRETCHEN HAMM L.M.H.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 W 20TH ST
JACKSONVILLE FL
32254-1703
US

IV. Provider business mailing address

PO BOX 19249
JACKSONVILLE FL
32245-9249
US

V. Phone/Fax

Practice location:
  • Phone: 904-695-9145
  • Fax: 904-493-4460
Mailing address:
  • Phone: 904-743-1883
  • Fax: 904-680-5451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH7179
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: