Provider Demographics
NPI:1821862954
Name:SULLIVAN, DEYJA
Entity Type:Individual
Prefix:
First Name:DEYJA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REN
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12276 SAN JOSE BLVD STE 508
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8618
Mailing Address - Country:US
Mailing Address - Phone:190-480-3584
Mailing Address - Fax:
Practice Address - Street 1:12276 SAN JOSE BLVD
Practice Address - Street 2:508
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8618
Practice Address - Country:US
Practice Address - Phone:904-886-3228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician