Provider Demographics
NPI:1336654417
Name:OWENS, VALISA CHARMAINE
Entity Type:Individual
Prefix:
First Name:VALISA
Middle Name:CHARMAINE
Last Name:OWENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VALISA
Other - Middle Name:C
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:7015 A C SKINNER PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6932
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-363-2606
Practice Address - Street 1:7015 A C SKINNER PKWY BLDG 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6932
Practice Address - Country:US
Practice Address - Phone:904-516-3737
Practice Address - Fax:904-516-3738
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW128331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJF349ZOtherMEDICARE