Provider Demographics
NPI:1871933887
Name:HARLEY, JAMICIA (EDD)
Entity type:Individual
Prefix:DR
First Name:JAMICIA
Middle Name:
Last Name:HARLEY
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 BALMORAL CIR N STE 209
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-5577
Mailing Address - Country:US
Mailing Address - Phone:904-660-8835
Mailing Address - Fax:
Practice Address - Street 1:3119 SPRING GLEN RD STE 115
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5921
Practice Address - Country:US
Practice Address - Phone:904-660-8835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106H00000X
106H00000X
FLCBHCMS.0100869171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015704500Medicaid