Provider Demographics
NPI:1104054030
Name:JACKSONVILLE YOUTH SANCTUARY
Entity type:Organization
Organization Name:JACKSONVILLE YOUTH SANCTUARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TARGETED CASE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:904-993-7955
Mailing Address - Street 1:4570 SAINT JOHNS AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-1848
Mailing Address - Country:US
Mailing Address - Phone:904-389-5231
Mailing Address - Fax:904-677-8019
Practice Address - Street 1:4570 SAINT JOHNS AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1848
Practice Address - Country:US
Practice Address - Phone:904-389-5231
Practice Address - Fax:904-677-8019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL360358001Medicaid