MEDICARE: CROWN VISION COMMUNITY HOME LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TM1800X	Intellectual & Developmental Disabilities Psychologist

General Provider Information

NPI Number	:	1619809571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN VISION COMMUNITY HOME LLC

Provider Business Mailing Address
First Line	:	5959 FORT CAROLINE RD APT 813
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32277-1826
Country	:	US
Telephone Number	:	904-469-6521
Fax Number	:

Provider Business Practice Location Address
First Line	:	5959 FORT CAROLINE RD APT 813
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32277-1826
Country	:	US
Telephone Number	:	904-469-6521
Fax Number	:

Authorized Official
Title or Position	:	OWNER / ADMINISTRATOR
Name	:	MR. JACQUISE ALEXANDER BROWN
Credential	:	OWNER /ADMINISTRATOR
Telephone Number	:	904-469-6521

Provider Enumeration Date	:	06/02/2026
Last Update Date	:	06/02/2026

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