Healthcare Provider Details

I. General information

NPI: 1518779800
Provider Name (Legal Business Name): TABITHA COBB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 PRUDENTIAL DR
JACKSONVILLE FL
32207-8105
US

IV. Provider business mailing address

917 TORTOISE WAY
JACKSONVILLE FL
32218-3698
US

V. Phone/Fax

Practice location:
  • Phone: 904-703-1768
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1472269
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: