Healthcare Provider Details

I. General information

NPI: 1992174627
Provider Name (Legal Business Name): JACINDA GOLDEN LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 PARK AVE STE 203
ORANGE PARK FL
32073-5558
US

IV. Provider business mailing address

2301 PARK AVE STE 203
ORANGE PARK FL
32073-5558
US

V. Phone/Fax

Practice location:
  • Phone: 904-203-8559
  • Fax: 904-592-5282
Mailing address:
  • Phone: 904-203-8559
  • Fax: 904-592-5282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW315
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: