Healthcare Provider Details

I. General information

NPI: 1821725060
Provider Name (Legal Business Name): INDEPENDENCE YOUTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14797 PHILIPS HWY STE 103
JACKSONVILLE FL
32256-3746
US

IV. Provider business mailing address

14797 PHILIPS HWY STE 103
JACKSONVILLE FL
32256-3746
US

V. Phone/Fax

Practice location:
  • Phone: 904-515-3735
  • Fax: 904-467-3422
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JANA SANFORD-HELLER
Title or Position: OWNER
Credential:
Phone: 904-515-3735