=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740099738
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENS MENTAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2025
-----------------------------------------------------
Last Update Date | 09/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1035 KINGS AVE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-8311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-833-4636
-----------------------------------------------------
Fax | 904-833-6636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1035 KINGS AVE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-8311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MAREK JOHN HIRSCH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 781-771-4285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------