Provider Demographics
NPI:1013161223
Name:MIELKE GROUP, INC.
Entity Type:Organization
Organization Name:MIELKE GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MIELKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:904-607-2079
Mailing Address - Street 1:7177 AUGUSTA DR
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8755
Mailing Address - Country:US
Mailing Address - Phone:904-607-2079
Mailing Address - Fax:904-384-0094
Practice Address - Street 1:3 SHIRCLIFF WAY
Practice Address - Street 2:SUITE #333
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4757
Practice Address - Country:US
Practice Address - Phone:904-607-2079
Practice Address - Fax:904-384-0094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6839103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74187OtherBLUE CROSS AND BLUE SHIELD OF FLORIDA
DE=========OtherTRICARE