Provider Demographics
NPI:1992362404
Name:PALMER, IDA MARIE
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:MARIE
Last Name:PALMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6722 ARLINGTON EXPY # 570
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-7234
Mailing Address - Country:US
Mailing Address - Phone:904-601-8426
Mailing Address - Fax:
Practice Address - Street 1:6722 ARLINGTON EXPY # 570
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-7234
Practice Address - Country:US
Practice Address - Phone:904-601-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103TH0100X103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG18000033026Medicaid