Provider Demographics
NPI:1205261765
Name:JACKSONVILLE PSYCHIATRIC ASSOCIATION INC
Entity type:Organization
Organization Name:JACKSONVILLE PSYCHIATRIC ASSOCIATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IMTIAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RASUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-901-0394
Mailing Address - Street 1:10175 FORTUNE PKWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6746
Mailing Address - Country:US
Mailing Address - Phone:973-901-0394
Mailing Address - Fax:941-205-2422
Practice Address - Street 1:10175 FORTUNE PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6746
Practice Address - Country:US
Practice Address - Phone:904-379-8748
Practice Address - Fax:904-379-8796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1121782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty