Healthcare Provider Details

I. General information

NPI: 1346459625
Provider Name (Legal Business Name): MICHAEL JOHN HERKOV PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11512 LAKE MEAD AVE SUITE 301
JACKSONVILLE FL
32256
US

IV. Provider business mailing address

11512 LAKE MEAD AVE SUITE 301
JACKSONVILLE FL
32256
US

V. Phone/Fax

Practice location:
  • Phone: 904-645-0114
  • Fax: 904-645-0115
Mailing address:
  • Phone: 904-645-0114
  • Fax: 904-645-0115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY4681
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY4681
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPY4681
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPY4681
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY4681
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY4681
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY4681
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPY4681
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY4681
License Number StateFL
# 10
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPY4681
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: