Provider Demographics
NPI:1295075190
Name:FAMILY THERAPY ASSOCIATES OF JACKSONVILLE LLC
Entity type:Organization
Organization Name:FAMILY THERAPY ASSOCIATES OF JACKSONVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:904-302-5340
Mailing Address - Street 1:2950 HALCYON LN STE 605
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-6692
Mailing Address - Country:US
Mailing Address - Phone:904-302-5340
Mailing Address - Fax:904-800-1211
Practice Address - Street 1:2950 HALCYON LN STE 605
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-6692
Practice Address - Country:US
Practice Address - Phone:904-302-5340
Practice Address - Fax:904-800-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2673251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health