Healthcare Provider Details

I. General information

NPI: 1770075509
Provider Name (Legal Business Name): THERESA G COUNCIL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA JOLLEY-COUNCIL

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 MELSON AVE
JACKSONVILLE FL
32254-1853
US

IV. Provider business mailing address

2815 MELSON AVE
JACKSONVILLE FL
32254-1853
US

V. Phone/Fax

Practice location:
  • Phone: 904-570-9418
  • Fax: 904-570-9418
Mailing address:
  • Phone: 904-570-9418
  • Fax: 904-570-9418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: