Healthcare Provider Details

I. General information

NPI: 1376276527
Provider Name (Legal Business Name): JOCELYN GONZALEZ ETHEREDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3547 HENDRICKS AVE
JACKSONVILLE FL
32207-5309
US

IV. Provider business mailing address

10860 TRESTLE CT
JACKSONVILLE FL
32257-3336
US

V. Phone/Fax

Practice location:
  • Phone: 904-877-1100
  • Fax: 904-877-1200
Mailing address:
  • Phone: 904-412-1646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN9382630
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11021202
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: