=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073274403
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHELSEA TAYLOR MOON-TISON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2022
-----------------------------------------------------
Last Update Date | 10/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 PRUDENTIAL DR STE 510
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-8207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-376-3800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 748519
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-8519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-376-3800
-----------------------------------------------------
Fax | 904-391-0167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW17930
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------