Provider Demographics
NPI:1235264482
Name:MEDINA, BETH ANN
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:MEDINA
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 1:13241 BARTRAM PARK BLVD UNIT 301
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5236
Mailing Address - Country:US
Mailing Address - Phone:904-268-1696
Mailing Address - Fax:
Practice Address - Street 1:13241 BARTRAM PARK BLVD UNIT 301
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258
Practice Address - Country:US
Practice Address - Phone:904-268-1696
Practice Address - Fax:844-864-3674
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6748101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health