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General NPI Number Information
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NPI Number | 1821725060
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Entity Type | Organization
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Legal Business Name | INDEPENDENCE YOUTH CENTER
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Dates
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Enumeration Date | 08/08/2022
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Last Update Date | 08/08/2022
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Provider Practice Location Address
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Address Line | 14797 PHILIPS HWY STE 103
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City | JACKSONVILLE
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State | FL
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Zip | 32256-3746
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Country | US
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Telephone | 904-515-3735
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Fax | 904-467-3422
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Provider Business Mailing Address
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Address Line | 14797 PHILIPS HWY STE 103
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City | JACKSONVILLE
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State | FL
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Zip | 32256-3746
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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 | JANA SANFORD-HELLER
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Credential |
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Telephone | 904-515-3735
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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