Healthcare Provider Details

I. General information

NPI: 1659893998
Provider Name (Legal Business Name): HEAVENLY HOME SWEET HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3733 UNIVERSITY BLVD W STE 202
JACKSONVILLE FL
32217-2152
US

IV. Provider business mailing address

15770 STEDMAN LAKE DR
JACKSONVILLE FL
32218-0619
US

V. Phone/Fax

Practice location:
  • Phone: 904-862-7700
  • Fax: 888-402-9512
Mailing address:
  • Phone: 904-554-2185
  • Fax: 888-402-9512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. GAIL JAMES
Title or Position: CEO
Credential: PHD.
Phone: 904-862-7700