Provider Demographics
NPI:1013573039
Name:MILLER-MAULTSBY, ANTIONETTE JARSHAWN
Entity Type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:JARSHAWN
Last Name:MILLER-MAULTSBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 WILL SCARLET RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-1154
Mailing Address - Country:US
Mailing Address - Phone:904-352-0066
Mailing Address - Fax:
Practice Address - Street 1:4401 WILL SCARLET RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-1154
Practice Address - Country:US
Practice Address - Phone:904-352-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103TH0100X103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service