Provider Demographics
NPI:1730903360
Name:HOLNESS, FATISHA RAYNELL
Entity type:Individual
Prefix:
First Name:FATISHA
Middle Name:RAYNELL
Last Name:HOLNESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6645 S STATE ROAD 121
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-5439
Mailing Address - Country:US
Mailing Address - Phone:646-897-4317
Mailing Address - Fax:
Practice Address - Street 1:4070 HERSCHEL ST STE 11706
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-2266
Practice Address - Country:US
Practice Address - Phone:904-567-0813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH27455101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health