Provider Demographics
NPI:1821575143
Name:PEDERSON, STEPHEN MARK
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 BELVEDERE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-7942
Mailing Address - Country:US
Mailing Address - Phone:612-250-7503
Mailing Address - Fax:
Practice Address - Street 1:13553 ATLANTIC BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-4227
Practice Address - Country:US
Practice Address - Phone:904-420-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician