Provider Demographics
NPI:1902066160
Name:URBAN JACKSONVILLE, INC
Entity Type:Organization
Organization Name:URBAN JACKSONVILLE, INC
Other - Org Name:AGING TRUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-807-1240
Mailing Address - Street 1:4250 LAKESIDE DR STE 116
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-3300
Mailing Address - Country:US
Mailing Address - Phone:904-807-1203
Mailing Address - Fax:904-807-1220
Practice Address - Street 1:4250 LAKESIDE DR STE 116
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3300
Practice Address - Country:US
Practice Address - Phone:904-807-1203
Practice Address - Fax:904-807-1220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
FL299993139251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105912900Medicaid