Healthcare Provider Details

I. General information

NPI: 1649426065
Provider Name (Legal Business Name): MARJORIE G. CUPP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 PARKWOOD ST
JACKSONVILLE FL
32207-5476
US

IV. Provider business mailing address

1545 PARKWOOD ST
JACKSONVILLE FL
32207-5476
US

V. Phone/Fax

Practice location:
  • Phone: 904-858-9740
  • Fax: 904-733-2681
Mailing address:
  • Phone: 904-858-9740
  • Fax: 904-733-2681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateFL

VIII. Authorized Official

Name: MS. MARJORIE G. CUPP
Title or Position: PROVIDER
Credential:
Phone: 904-858-9740