Provider Demographics
NPI:1831246131
Name:MIELKE, JEANNINE BOYLE (PHD)
Entity type:Individual
Prefix:MRS
First Name:JEANNINE
Middle Name:BOYLE
Last Name:MIELKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:JEANNINE
Other - Middle Name:MARIE
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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:904-529-7441
Mailing Address - Fax:904-529-7440
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0006839103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74187OtherBCBSF
FL74187OtherBCBSF