Healthcare Provider Details

I. General information

NPI: 1942350442
Provider Name (Legal Business Name): KORI LEE SEDGLEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KORI LEE WHITAKER LCSW

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2354 UNIVERSITY BLVD N
JACKSONVILLE FL
32211-3228
US

IV. Provider business mailing address

2354 UNIVERSITY BLVD N
JACKSONVILLE FL
32211-3228
US

V. Phone/Fax

Practice location:
  • Phone: 904-421-6058
  • Fax: 904-744-8131
Mailing address:
  • Phone: 904-421-6058
  • Fax: 904-744-8131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7058
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: