Provider Demographics
NPI:1790259489
Name:MAYNARD, LATANYA RENEE (MA)
Entity Type:Individual
Prefix:
First Name:LATANYA
Middle Name:RENEE
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2392 EDGEWOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-1725
Mailing Address - Country:US
Mailing Address - Phone:904-781-7797
Mailing Address - Fax:
Practice Address - Street 1:1131 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-4094
Practice Address - Country:US
Practice Address - Phone:904-866-5717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor