Provider Demographics
NPI:1134276140
Name:J NICHOLAS PREWETT PHD & ASSOCIATES PA
Entity type:Organization
Organization Name:J NICHOLAS PREWETT PHD & ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHANN
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:PREWETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:904-269-6071
Mailing Address - Street 1:1726 KINGSLEY AVE
Mailing Address - Street 2:SUITE 12
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4463
Mailing Address - Country:US
Mailing Address - Phone:904-269-6071
Mailing Address - Fax:904-269-6642
Practice Address - Street 1:1726 KINGSLEY AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4463
Practice Address - Country:US
Practice Address - Phone:904-269-6071
Practice Address - Fax:904-269-6642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6231101YM0800X
FLPY4331103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty