Provider Demographics
NPI:1629848866
Name:ICON, JUANA R
Entity Type:Individual
Prefix:
First Name:JUANA
Middle Name:R
Last Name:ICON
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:PO BOX 8489
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32239-0489
Mailing Address - Country:US
Mailing Address - Phone:772-333-5100
Mailing Address - Fax:
Practice Address - Street 1:7925 MERRILL RD APT 2107
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-6540
Practice Address - Country:US
Practice Address - Phone:772-333-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst