Provider Demographics
NPI:1710589205
Name:SANKOFA BEHAVIORAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:SANKOFA BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMHC
Authorized Official - Prefix:DR
Authorized Official - First Name:MIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:904-891-6614
Mailing Address - Street 1:PO BOX 8056
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32239-0056
Mailing Address - Country:US
Mailing Address - Phone:904-891-6614
Mailing Address - Fax:904-512-6614
Practice Address - Street 1:5379 LENOX AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-4737
Practice Address - Country:US
Practice Address - Phone:904-891-6614
Practice Address - Fax:904-512-6614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health