Provider Demographics
NPI:1366558132
Name:MENTAL HEALTH CENTER OF JACKSONVILLE, INC.
Entity type:Organization
Organization Name:MENTAL HEALTH CENTER OF JACKSONVILLE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:904-743-1883
Mailing Address - Street 1:PO BOX 19189
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-9189
Mailing Address - Country:US
Mailing Address - Phone:904-743-1883
Mailing Address - Fax:904-743-5109
Practice Address - Street 1:3333 W 20TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1703
Practice Address - Country:US
Practice Address - Phone:904-695-9145
Practice Address - Fax:904-695-2465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2015-01-26
Deactivation Date:2014-12-29
Deactivation Code:
Reactivation Date:2015-01-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251B00000XAgenciesCase Management
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060366002Medicaid
FL060366000Medicaid
FL00444Medicare ID - Type UnspecifiedPART B