Healthcare Provider Details

I. General information

NPI: 1447546791
Provider Name (Legal Business Name): MS. LORETTA DONALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 POWHATTAN ST
JACKSONVILLE FL
32209-6023
US

IV. Provider business mailing address

1620 POWHATTAN ST
JACKSONVILLE FL
32209-6023
US

V. Phone/Fax

Practice location:
  • Phone: 904-551-0851
  • Fax: 904-551-0851
Mailing address:
  • Phone: 904-551-0851
  • Fax: 904-551-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number6906743
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: