Provider Demographics
NPI:1982401428
Name:MYERS, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MYERS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 FAIRWAY VILLAS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32233-0013
Mailing Address - Country:US
Mailing Address - Phone:904-699-1190
Mailing Address - Fax:
Practice Address - Street 1:2305 FAIRWAY VILLAS DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32233-0013
Practice Address - Country:US
Practice Address - Phone:904-699-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH27214101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health