Provider Demographics
NPI:1154430197
Name:MARLYN ENTERPRISES OF JACKSONVILLE, INC.
Entity type:Organization
Organization Name:MARLYN ENTERPRISES OF JACKSONVILLE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ULERIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-398-2020
Mailing Address - Street 1:11265 ALUMNI WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-6685
Mailing Address - Country:US
Mailing Address - Phone:904-398-2020
Mailing Address - Fax:904-724-2172
Practice Address - Street 1:11265 ALUMNI WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-6685
Practice Address - Country:US
Practice Address - Phone:904-398-2020
Practice Address - Fax:904-724-2172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL678170596Medicaid
FL678170596Medicaid