Healthcare Provider Details

I. General information

NPI: 1417609645
Provider Name (Legal Business Name): OWIMAST HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10245 CENTURION PKWY N STE 200
JACKSONVILLE FL
32256-0569
US

IV. Provider business mailing address

10245 CENTURION PKWY N STE 200
JACKSONVILLE FL
32256-0569
US

V. Phone/Fax

Practice location:
  • Phone: 904-674-3521
  • Fax: 888-595-4335
Mailing address:
  • Phone: 888-803-5543
  • Fax: 888-595-4335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: SUMMER WHITAKER
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 888-803-5543