Healthcare Provider Details

I. General information

NPI: 1861854564
Provider Name (Legal Business Name): JACKSONVILLE WOLFSON CHILDRENS HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14785 OLD SAINT AUGUSTINE RD
JACKSONVILLE FL
32258-2496
US

IV. Provider business mailing address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8202
US

V. Phone/Fax

Practice location:
  • Phone: 904-346-0394
  • Fax:
Mailing address:
  • Phone: 904-202-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License NumberSLP006732
License Number StateGA

VIII. Authorized Official

Name: MRS. SUZANNE GAETA-BARJE
Title or Position: REHAB SUPERVISOR
Credential: PT
Phone: 904-292-1808