Healthcare Provider Details

I. General information

NPI: 1053706507
Provider Name (Legal Business Name): SUCCESSFUL WOMEN ACKNOWLEDGED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5991 CHESTER AVE STE 211
JACKSONVILLE FL
32217-2245
US

IV. Provider business mailing address

5991 CHESTER AVE STE 211
JACKSONVILLE FL
32217-2245
US

V. Phone/Fax

Practice location:
  • Phone: 904-566-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number3852
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number3852
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number3852
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number3852
License Number StateFL

VIII. Authorized Official

Name: TIFFANY S WELLS
Title or Position: FOUNDER CEO
Credential: B.S. M.S. CWCM, CPI
Phone: 904-566-0200