Provider Demographics
NPI:1598949018
Name:ST JOHNS CO COUNCIL ON AGING
Entity Type:Organization
Organization Name:ST JOHNS CO COUNCIL ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:YANNI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-209-3685
Mailing Address - Street 1:180 MARINE ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5153
Mailing Address - Country:US
Mailing Address - Phone:904-209-3700
Mailing Address - Fax:904-209-3663
Practice Address - Street 1:180 MARINE ST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5153
Practice Address - Country:US
Practice Address - Phone:904-209-3700
Practice Address - Fax:904-209-3663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 332U00000X, 343900000X, 385H00000X
FL5857251E00000X
FL9004261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No332U00000XSuppliersHome Delivered Meals
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL099507000Medicaid
FL024894101Medicaid
FL099507001Medicaid
FL113734100Medicaid
FL689228100Medicaid