Healthcare Provider Details

I. General information

NPI: 1316755820
Provider Name (Legal Business Name): CRYSTAL MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6196 LAKE GRAY BLVD STE 117
JACKSONVILLE FL
32244-5867
US

IV. Provider business mailing address

6196 LAKE GRAY BLVD STE 117
JACKSONVILLE FL
32244-5867
US

V. Phone/Fax

Practice location:
  • Phone: 904-456-1204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: