Healthcare Provider Details

I. General information

NPI: 1629362421
Provider Name (Legal Business Name): LASHONDA JESSICA MCGRIFF LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 ATLANTIC BLVD
JACKSONVILLE FL
32207-2038
US

IV. Provider business mailing address

4111 ATLANTIC BLVD
JACKSONVILLE FL
32207-2038
US

V. Phone/Fax

Practice location:
  • Phone: 904-210-4022
  • Fax:
Mailing address:
  • Phone: 904-210-4022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberMA28203
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: