Healthcare Provider Details

I. General information

NPI: 1467127506
Provider Name (Legal Business Name): AGAPE COMMUNITY HEALTH MOBILE UNIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 EDGEWOOD AVE S
JACKSONVILLE FL
32205-9118
US

IV. Provider business mailing address

120 KING ST
JACKSONVILLE FL
32204-2410
US

V. Phone/Fax

Practice location:
  • Phone: 904-760-4904
  • Fax:
Mailing address:
  • Phone: 904-800-6347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JILLIAN SCHELLHAMMER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 904-800-6347