Healthcare Provider Details

I. General information

NPI: 1467110692
Provider Name (Legal Business Name): MR. JOSEPH GRANT JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CENTURY 21 DRIVE STE 213 PMB 148
JACKSONVILLE FL
32216
US

IV. Provider business mailing address

103 CENTURY 21 DRIVE STE 213 PMB 148
JACKSONVILLE FL
32216
US

V. Phone/Fax

Practice location:
  • Phone: 904-401-2032
  • Fax:
Mailing address:
  • Phone: 904-401-2032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberL21000489498
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: