Healthcare Provider Details

I. General information

NPI: 1558736587
Provider Name (Legal Business Name): SHARONDA R. HUSSEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11501 BRIAN LAKES DR
JACKSONVILLE FL
32221-2849
US

IV. Provider business mailing address

11501 BRIAN LAKES DR
JACKSONVILLE FL
32221-2849
US

V. Phone/Fax

Practice location:
  • Phone: 904-229-1884
  • Fax:
Mailing address:
  • Phone: 904-229-1884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateFL

VIII. Authorized Official

Name: MS. SHARONDA HUSSEY
Title or Position: PROVIDER
Credential:
Phone: 904-229-1884