Provider Demographics
NPI:1669037388
Name:MALONE, JAMES DALLAS
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DALLAS
Last Name:MALONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 LAUREL GROVE LN
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5519
Mailing Address - Country:US
Mailing Address - Phone:407-267-8837
Mailing Address - Fax:
Practice Address - Street 1:5964 US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060-8694
Practice Address - Country:US
Practice Address - Phone:386-963-6530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16907101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health