Provider Demographics
NPI:1679343982
Name:ISAAC, KERVIN
Entity Type:Individual
Prefix:MR
First Name:KERVIN
Middle Name:
Last Name:ISAAC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KERVIN
Other - Middle Name:
Other - Last Name:ISAAC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7816 SOUTHSIDE BLVD APT 13
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7042
Mailing Address - Country:US
Mailing Address - Phone:239-821-6315
Mailing Address - Fax:
Practice Address - Street 1:7816 SOUTHSIDE BLVD APT 13
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7042
Practice Address - Country:US
Practice Address - Phone:239-821-6315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH22980101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health