Provider Demographics
NPI:1336694645
Name:EVERSON, EDWARD III
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:EVERSON
Suffix:III
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 1:3239 JUSTINA RD
Mailing Address - Street 2:APT.58
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-3191
Mailing Address - Country:US
Mailing Address - Phone:904-660-8341
Mailing Address - Fax:
Practice Address - Street 1:1419 UNIVERSITY BLVD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5249
Practice Address - Country:US
Practice Address - Phone:904-745-0067
Practice Address - Fax:904-745-1030
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor