Healthcare Provider Details

I. General information

NPI: 1922501493
Provider Name (Legal Business Name): J CHURCHWELL COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N PONCE DE LEON BLVD STE 3
ST AUGUSTINE FL
32084-2650
US

IV. Provider business mailing address

2200 N PONCE DE LEON BLVD STE 3
ST AUGUSTINE FL
32084-2650
US

V. Phone/Fax

Practice location:
  • Phone: 904-377-4200
  • Fax: 904-485-8019
Mailing address:
  • Phone: 904-377-4200
  • Fax: 904-485-8019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JILL YOERGER-CHURCHWELL
Title or Position: OWNER
Credential: LCSW
Phone: 904-377-4200