Provider Demographics
NPI:1003166307
Name:FRESH START PRIVATE FLORIDA
Entity Type:Organization
Organization Name:FRESH START PRIVATE FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JON
Authorized Official - Last Name:JACKOBOICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-591-6240
Mailing Address - Street 1:1415 PANTHER LN
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-7874
Mailing Address - Country:US
Mailing Address - Phone:239-591-6240
Mailing Address - Fax:
Practice Address - Street 1:1415 PANTHER LN
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-7874
Practice Address - Country:US
Practice Address - Phone:239-591-6240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health