Provider Demographics
NPI:1174017933
Name:VEGA, COURTNEY ALISSA
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:ALISSA
Last Name:VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:COURTNEY
Other - Middle Name:ALISSA
Other - Last Name:WHITTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8011 PHILIPS HWY STE 10
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7459
Mailing Address - Country:US
Mailing Address - Phone:904-928-0112
Mailing Address - Fax:904-647-9489
Practice Address - Street 1:8011 PHILIPS HWY STE 10
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7459
Practice Address - Country:US
Practice Address - Phone:904-928-0112
Practice Address - Fax:904-647-9489
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician