Healthcare Provider Details

I. General information

NPI: 1174803225
Provider Name (Legal Business Name): JOHNNY BANKS B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 N JEFFERSON ST
JACKSONVILLE FL
32209-6810
US

IV. Provider business mailing address

2568 MAPLE STAND CT
JACKSONVILLE FL
32221-3839
US

V. Phone/Fax

Practice location:
  • Phone: 904-360-7022
  • Fax: 904-798-4544
Mailing address:
  • Phone: 904-781-2272
  • Fax: 904-328-3756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: