Healthcare Provider Details

I. General information

NPI: 1558048405
Provider Name (Legal Business Name): JEM THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 KINGSLEY AVE, BLDG 9, SUITE D
ORANGE PARK FL
32073-4537
US

IV. Provider business mailing address

1409 KINGSLEY AVE, BLDG 9, SUITE D
ORANGE PARK FL
32073-4537
US

V. Phone/Fax

Practice location:
  • Phone: 904-773-4665
  • Fax: 904-773-4668
Mailing address:
  • Phone: 904-773-4665
  • Fax: 904-773-4668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER MATILLA
Title or Position: LICENSED MENTAL HEALTH COUNSELOR/QU
Credential: LMHC
Phone: 904-773-4665