Provider Demographics
NPI:1316439698
Name:LAND, JAMES ALFRED (MS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ALFRED
Last Name:LAND
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 W HIGHWAY 98 UNIT B7
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-4718
Mailing Address - Country:US
Mailing Address - Phone:850-693-6518
Mailing Address - Fax:
Practice Address - Street 1:212 W HIGHWAY 98 STE C
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1301
Practice Address - Country:US
Practice Address - Phone:850-705-1766
Practice Address - Fax:850-705-1767
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020897000Medicaid