=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245641646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JMH DEVELOPMENT USA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2014
-----------------------------------------------------
Last Update Date | 01/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4375 US HIGHWAY 17 SUITE 103
-----------------------------------------------------
City | FLEMING ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32003-4832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-269-0886
-----------------------------------------------------
Fax | 904-269-0499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4375 US HIGHWAY 17 SUITE 103
-----------------------------------------------------
City | FLEMING ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32003-4832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-269-0886
-----------------------------------------------------
Fax | 904-269-0499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JASON MATTHEW HOSCH
-----------------------------------------------------
Credential | PHD, LMHC, LCCC
-----------------------------------------------------
Telephone | 904-269-0886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH5348
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------