Healthcare Provider Details

I. General information

NPI: 1235901141
Provider Name (Legal Business Name): GATEWAY COMMUNITY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 STOCKTON ST
JACKSONVILLE FL
32204-2534
US

IV. Provider business mailing address

555 STOCKTON ST
JACKSONVILLE FL
32204-2534
US

V. Phone/Fax

Practice location:
  • Phone: 904-387-4661
  • Fax: 904-361-5005
Mailing address:
  • Phone: 904-387-4661
  • Fax: 904-361-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAWANDA HOLLOWAY
Title or Position: UR/INSURANCE SPECIALIST
Credential: LMHC, MCAP
Phone: 904-387-4661