Provider Demographics
NPI:1104341601
Name:WEIGHTMAN, HOWARD EVANS III
Entity type:Individual
Prefix:
First Name:HOWARD
Middle Name:EVANS
Last Name:WEIGHTMAN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5751 DICKSON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211
Mailing Address - Country:US
Mailing Address - Phone:904-418-4019
Mailing Address - Fax:
Practice Address - Street 1:943 CESERY BLVD
Practice Address - Street 2:STE G
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211
Practice Address - Country:US
Practice Address - Phone:904-745-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21609101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty