=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023467347
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARYLIN PALACKEL JAMES D.O
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2016
-----------------------------------------------------
Last Update Date | 01/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 3RD ST SOUTH SUITE 3004 B
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-5266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-902-0150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 STATE RD 13 NORTH SUITE 106 PMB 157
-----------------------------------------------------
City | ST. JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-902-0150
-----------------------------------------------------
Fax | 904-902-7172
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS15761
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------