Healthcare Provider Details

I. General information

NPI: 1750988895
Provider Name (Legal Business Name): COFFEE & GRACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 10/31/2020
Certification Date: 10/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 N PEARL ST STE A
JACKSONVILLE FL
32206-3663
US

IV. Provider business mailing address

PO BOX 77581
JACKSONVILLE FL
32226-7581
US

V. Phone/Fax

Practice location:
  • Phone: 904-474-2192
  • Fax: 904-212-0128
Mailing address:
  • Phone: 904-474-2192
  • Fax: 904-212-0128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALYSSA JACOBS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 904-474-2192