=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558230664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAECYN BEHAVIORAL HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2025
-----------------------------------------------------
Last Update Date | 01/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10131 FOX LAKE CT
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32219-1693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-525-0418
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10131 FOX LAKE CT
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32219-1693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-525-0418
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CAMEILA YONNIQUE KELLY
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 904-525-0418
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------