=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598195653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOX MENTAL HELATH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2013
-----------------------------------------------------
Last Update Date | 11/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12627 SAN JOSE BLVD STE 901C
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-8645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-716-8594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12627 SAN JOSE BLVD STE 901C
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-8645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-716-8594
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SCARLETT FERN KIBBEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-716-8594
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------