Healthcare Provider Details

I. General information

NPI: 1114732476
Provider Name (Legal Business Name): BROOKE GRANT LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/12/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14979 PHILLIPS HIGHWAY SUITE 108
JACKSONVILLE FL
32256
US

IV. Provider business mailing address

1045 INWOOD TER
JACKSONVILLE FL
32207-4250
US

V. Phone/Fax

Practice location:
  • Phone: 904-223-9100
  • Fax:
Mailing address:
  • Phone: 904-652-9138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH24210
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: