Provider Demographics
NPI:1407400591
Name:AUTHENTIC SELF COUNSELING OF JACKSONVILLE, LLC
Entity Type:Organization
Organization Name:AUTHENTIC SELF COUNSELING OF JACKSONVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-990-7117
Mailing Address - Street 1:3733 UNIVERSITY BLVD W STE 203
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2152
Mailing Address - Country:US
Mailing Address - Phone:904-990-7117
Mailing Address - Fax:
Practice Address - Street 1:3733 UNIVERSITY BLVD W STE 203
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2152
Practice Address - Country:US
Practice Address - Phone:904-990-7117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-28
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1117302000Medicaid
1417447319OtherNPI