Provider Demographics
NPI:1104303973
Name:JARVIS, KIRSTIN NICOLE
Entity type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:NICOLE
Last Name:JARVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 COUNTY ROAD 220 APT 3707
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-9124
Mailing Address - Country:US
Mailing Address - Phone:904-314-5741
Mailing Address - Fax:
Practice Address - Street 1:804 3RD ST STE AB
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-5040
Practice Address - Country:US
Practice Address - Phone:904-701-2926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-60771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-18-60771Medicaid