Healthcare Provider Details

I. General information

NPI: 1932258555
Provider Name (Legal Business Name): MRS. MELANIE JILL O'BRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 HANOVER PARK DR
JACKSONVILLE FL
32224-8602
US

IV. Provider business mailing address

4308 HANOVER PARK DR
JACKSONVILLE FL
32224-8602
US

V. Phone/Fax

Practice location:
  • Phone: 904-465-1049
  • Fax: 904-438-5423
Mailing address:
  • Phone: 904-465-1049
  • Fax: 904-438-5423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: