Provider Demographics
NPI:1043077720
Name:JUDGE, ELIJAH ANTHONY
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:ANTHONY
Last Name:JUDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4257 PACKARD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-6466
Mailing Address - Country:US
Mailing Address - Phone:352-857-6421
Mailing Address - Fax:
Practice Address - Street 1:6820 SOUTHPOINT PKWY STE 9
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6277
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician