Healthcare Provider Details

I. General information

NPI: 1013848209
Provider Name (Legal Business Name): SECOND CHANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5494 LOGAN CAVE AVE
WIMAUMA FL
33598-2440
US

IV. Provider business mailing address

PO BOX 35225
ST PETERSBURG FL
33705-0504
US

V. Phone/Fax

Practice location:
  • Phone: 727-265-0224
  • Fax:
Mailing address:
  • Phone: 727-265-0224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM JACKSON
Title or Position: OWNER
Credential:
Phone: 727-265-0224