Healthcare Provider Details

I. General information

NPI: 1104996651
Provider Name (Legal Business Name): JOHN GLENN GAST LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810-3 WILLIAMSBURG PARK BLVD
JACKSONVILLE FL
32257-9220
US

IV. Provider business mailing address

3810-3 WILLIAMSBURG PARK BLVD
JACKSONVILLE FL
32257-9220
US

V. Phone/Fax

Practice location:
  • Phone: 904-419-6102
  • Fax: 904-739-2153
Mailing address:
  • Phone: 904-419-6102
  • Fax: 904-739-2153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH5616
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: