Provider Demographics
NPI:1932139425
Name:FERNANDEZ, MARY JO FRANCES (PHD)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:FRANCES
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11307 NW 60TH TER
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-7415
Mailing Address - Country:US
Mailing Address - Phone:781-710-6539
Mailing Address - Fax:
Practice Address - Street 1:1135 NW 23RD AVE
Practice Address - Street 2:SUITE G
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-5415
Practice Address - Country:US
Practice Address - Phone:781-710-6539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7249103T00000X
FLPY 9485103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
401761OtherTUFTS
MAW05960OtherBCBS
MA0501417Medicaid
MAW05960OtherBCBS