Healthcare Provider Details

I. General information

NPI: 1912494246
Provider Name (Legal Business Name): SERENITY RESIDENTIAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 UNIVERSITY BLVD W
JACKSONVILLE FL
32217-2002
US

IV. Provider business mailing address

2406 UNIVERSITY BLVD W
JACKSONVILLE FL
32217-2002
US

V. Phone/Fax

Practice location:
  • Phone: 904-379-8914
  • Fax: 904-800-1465
Mailing address:
  • Phone: 904-379-8914
  • Fax: 904-800-1465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. LAUREN ASHLEE THOMAS
Title or Position: VICE PRESIDENT
Credential:
Phone: 904-379-8914