Provider Demographics
NPI:1104996651
Name:GAST, JOHN GLENN (LMHC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:GLENN
Last Name:GAST
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810-3 WILLIAMSBURG PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-9220
Mailing Address - Country:US
Mailing Address - Phone:904-419-6102
Mailing Address - Fax:904-739-2153
Practice Address - Street 1:3810-3 WILLIAMSBURG PARK BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-9220
Practice Address - Country:US
Practice Address - Phone:904-419-6102
Practice Address - Fax:904-739-2153
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5616101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health