Healthcare Provider Details

I. General information

NPI: 1639691108
Provider Name (Legal Business Name): DARBY GLACKIN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 RIVERSIDE AVE STE 190
JACKSONVILLE FL
32204-4189
US

IV. Provider business mailing address

85166 CHERRY CREEK DR
FERNANDINA BEACH FL
32034-3779
US

V. Phone/Fax

Practice location:
  • Phone: 904-647-4284
  • Fax:
Mailing address:
  • Phone: 845-803-1158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14230
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: