MEDICARE: A NEW DIRECTION BREAKING THE CYCLE OF POVERTY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor
3	103TC1900X	Counseling Psychologist
4	106H00000X	Marriage & Family Therapist
5	251S00000X	Community/Behavioral Health Agency
6	251V00000X	Voluntary or Charitable Agency
7	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306104872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A NEW DIRECTION BREAKING THE CYCLE OF POVERTY

Provider Business Mailing Address
First Line	:	320 1ST ST N STE 612
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6947
Country	:	US
Telephone Number	:	334-647-1009
Fax Number	:	888-856-7677

Provider Business Practice Location Address
First Line	:	320 1ST ST N STE 612
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6947
Country	:	US
Telephone Number	:	334-647-1009
Fax Number	:	888-856-7677

Authorized Official
Title or Position	:	CEO
Name	:	JEFKIDA LASHA JOHNSON
Credential	:
Telephone Number	:	334-320-0084

Provider Enumeration Date	:	05/02/2012
Last Update Date	:	04/26/2022

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Directions to “A NEW DIRECTION BREAKING THE CYCLE OF POVERTY ” Practice Location

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