Provider Demographics
NPI:1578721759
Name:JOY-LITTLE, LAKEISHA
Entity Type:Individual
Prefix:
First Name:LAKEISHA
Middle Name:
Last Name:JOY-LITTLE
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 1:15744 BAINEBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-8349
Mailing Address - Country:US
Mailing Address - Phone:904-469-5933
Mailing Address - Fax:
Practice Address - Street 1:15744 BAINEBRIDGE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-8349
Practice Address - Country:US
Practice Address - Phone:904-469-5933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-24
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
FL320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689847596Medicaid