Provider Demographics
NPI:1881636553
Name:MOONEYHAM, SJOUKJE ODETTE (CNM/ARNP)
Entity Type:Individual
Prefix:
First Name:SJOUKJE
Middle Name:ODETTE
Last Name:MOONEYHAM
Suffix:
Gender:F
Credentials:CNM/ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 MERRIMAC AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-1850
Mailing Address - Country:US
Mailing Address - Phone:904-346-0050
Mailing Address - Fax:904-346-0080
Practice Address - Street 1:4425 MERRIMAC AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1850
Practice Address - Country:US
Practice Address - Phone:904-346-0050
Practice Address - Fax:904-346-0080
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3408202367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003110725AMedicaid
FL3078418Medicaid