Provider Demographics
NPI:1861854564
Name:JACKSONVILLE WOLFSON CHILDRENS HOSPITAL
Entity type:Organization
Organization Name:JACKSONVILLE WOLFSON CHILDRENS HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REHAB SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAETA-BARJE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:904-292-1808
Mailing Address - Street 1:800 PRUDENTIAL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8202
Mailing Address - Country:US
Mailing Address - Phone:904-202-8000
Mailing Address - Fax:
Practice Address - Street 1:14785 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2496
Practice Address - Country:US
Practice Address - Phone:904-346-0394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006732261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)