Healthcare Provider Details

I. General information

NPI: 1164307997
Provider Name (Legal Business Name): LEA R BUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/11/2025
Certification Date: 08/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14600 WHIRLWIND AVE
JACKSONVILLE FL
32218-9437
US

IV. Provider business mailing address

4408 SUN LILY CT
JACKSONVILLE FL
32257-8099
US

V. Phone/Fax

Practice location:
  • Phone: 904-447-7577
  • Fax:
Mailing address:
  • Phone: 904-710-3854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: