Healthcare Provider Details

I. General information

NPI: 1154873016
Provider Name (Legal Business Name): FAMILY FOUNDATIONS OF NORTHEAST FLORIDA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 E ADAMS ST STE LL15
JACKSONVILLE FL
32202-3353
US

IV. Provider business mailing address

40 E ADAMS ST STE LL15
JACKSONVILLE FL
32202-3353
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-4846
  • Fax: 904-398-6649
Mailing address:
  • Phone: 904-396-4846
  • Fax: 904-398-6649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM JOSEPH HALEY
Title or Position: PRESIDENT & CEO
Credential:
Phone: 904-396-8127