Provider Demographics
NPI:1447898804
Name:TAYLOR, TOMMIE LASEAN (MA)
Entity type:Individual
Prefix:
First Name:TOMMIE
Middle Name:LASEAN
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 UNIVERSITY BLVD S STE 15
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4346
Mailing Address - Country:US
Mailing Address - Phone:904-745-0067
Mailing Address - Fax:
Practice Address - Street 1:4131 UNIVERSITY BLVD S STE 15
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4346
Practice Address - Country:US
Practice Address - Phone:904-745-0067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health