Provider Demographics
NPI:1093781064
Name:CMS JACKSONVILLE
Entity Type:Organization
Organization Name:CMS JACKSONVILLE
Other - Org Name:FLORIDA DEPARTMENT OF HEALTH CHILDRENS MEDICAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEATHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-334-1394
Mailing Address - Street 1:910 NORTH JEFFERSON STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6810
Mailing Address - Country:US
Mailing Address - Phone:904-360-7070
Mailing Address - Fax:904-798-4568
Practice Address - Street 1:910 NORTH JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6810
Practice Address - Country:US
Practice Address - Phone:904-360-7070
Practice Address - Fax:904-798-4568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare