Provider Demographics
NPI:1518521913
Name:YOUMANS- KENNY, HOLLY DAWN
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:DAWN
Last Name:YOUMANS- KENNY
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 1:9000 SOUTHSIDE BLVD BLDG 900
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0791
Mailing Address - Country:US
Mailing Address - Phone:904-732-4343
Mailing Address - Fax:904-562-3466
Practice Address - Street 1:2035 SW 75TH ST STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-3425
Practice Address - Country:US
Practice Address - Phone:352-332-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL55232489553106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSMedicaid
FL1518521913Medicaid