Healthcare Provider Details

I. General information

NPI: 1972524684
Provider Name (Legal Business Name): NORTHWEST BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2392 EDGEWOOD AVE N
JACKSONVILLE FL
32254-1725
US

IV. Provider business mailing address

2392 EDGEWOOD AVE N
JACKSONVILLE FL
32254-1725
US

V. Phone/Fax

Practice location:
  • Phone: 904-781-7797
  • Fax: 904-781-8729
Mailing address:
  • Phone: 904-781-7797
  • Fax: 904-781-8729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateFL

VIII. Authorized Official

Name: MS. PATRICIA G SAMPSON
Title or Position: CEO
Credential: MS, CAPP
Phone: 904-781-7797