MEDICARE: CROSSROADS HEALTH & WELLNESS CENTER

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	2084P0800X	Psychiatry Physician
3	251S00000X	Community/Behavioral Health Agency
4	261QH0100X	Health Service Clinic/Center
5	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1407520554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROADS HEALTH & WELLNESS CENTER

Provider Business Mailing Address
First Line	:	5960 BEACH BLVD STE 3
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5113
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5960 BEACH BLVD STE 3
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5113
Country	:	US
Telephone Number	:	904-358-1211
Fax Number	:

Authorized Official
Title or Position	:	ASSESSMENT COUNSELOR
Name	:	MARIANNA DOWELL
Credential	:
Telephone Number	:	904-701-0229

Provider Enumeration Date	:	08/03/2021
Last Update Date	:	08/05/2022

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