Healthcare Provider Details

I. General information

NPI: 1164338265
Provider Name (Legal Business Name): JACK ADAM FASTEEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S HARBOR CITY BLVD STE 401
MELBOURNE FL
32901-1389
US

IV. Provider business mailing address

200 S HARBOR CITY BLVD STE 401
MELBOURNE FL
32901-1389
US

V. Phone/Fax

Practice location:
  • Phone: 321-259-1662
  • Fax: 321-779-7729
Mailing address:
  • Phone: 321-259-1662
  • Fax: 321-779-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number27226
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: