Provider Demographics
NPI:1811513534
Name:CASEY CENTER FOR COMMUNITY COUNSELING
Entity type:Organization
Organization Name:CASEY CENTER FOR COMMUNITY COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JEDRZIEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:904-614-4190
Mailing Address - Street 1:2386 STOCKTON DR
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8787
Mailing Address - Country:US
Mailing Address - Phone:904-614-4190
Mailing Address - Fax:
Practice Address - Street 1:2386 STOCKTON DR
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-8787
Practice Address - Country:US
Practice Address - Phone:904-614-4190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-18
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty