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General NPI Number Information
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NPI Number | 1790340065
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Entity Type | Organization
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Legal Business Name | FULL CONNECTIONS COUNSELING
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Dates
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Enumeration Date | 05/02/2019
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Last Update Date | 06/25/2020
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Provider Practice Location Address
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Address Line | 752 BLANDING BLVD STE 130
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City | ORANGE PARK
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State | FL
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Zip | 32065-5790
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Country | US
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Telephone | 904-637-5297
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Fax |
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Provider Business Mailing Address
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Address Line | 3045 RUSSELL RD
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City | GREEN COVE SPRINGS
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State | FL
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Zip | 32043-8209
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DOMONIQUE JACKSON
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Credential | LCSW
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Telephone | 904-637-5297
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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