Provider Demographics
NPI:1780644203
Name:FELIXSON, JANICE (LCSW LMFT)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:FELIXSON
Suffix:
Gender:F
Credentials:LCSW LMFT
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:
Other - Last Name:FELIXSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW LMFT
Mailing Address - Street 1:PO BOX 4412
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-4412
Mailing Address - Country:US
Mailing Address - Phone:904-824-1152
Mailing Address - Fax:
Practice Address - Street 1:2200 NO PONCE DE LEON BLVD
Practice Address - Street 2:SUITE #3
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084
Practice Address - Country:US
Practice Address - Phone:904-824-1152
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW00028481041C0700X
FLMT0000584106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1338Medicare ID - Type Unspecified