NPIMap

Organization Active NPI

Florida Department of Children and Families

Doing business as Northeast Florida State Hospital

  • Psychiatric Hospital
  • Macclenny, FL
National Provider Identifier
1013931765
Registry record updated Nov 18, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric HospitalTaxonomy code 283Q00000X
License
4004 Issued in FL
Legal business name
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
Doing business as
Northeast Florida State Hospital
Practice address
7487 S State Road 121
Accounting Department
Macclenny, FL 32063-5451
Phone
(904) 259-6211
Fax
(904) 259-7154
NPI assigned
Jul 26, 2006
Last updated
Nov 18, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 18, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Linda G. Williams
Title
Hospital Administrator
Phone
(904) 330-2001

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital 283Q00000X 4004 FL Primary

Addresses

Primary practice location

7487 S State Road 121
Accounting Department
Macclenny, FL 32063-5451

Mailing address

7487 S State Road 121
Accounting Department
Macclenny, FL 32063-5480
Phone (904) 259-6211

Other identifiers 1

IdentifierTypeStateIssuer
026002900MedicaidFL

Other names 1

  • Northeast Florida State Hospital Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031222000351 FL Part B Supplier - Clinic/Group Practice 5092613570 Receives reassigned benefits from 90 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Chattahoochee, FL; Macclenny, FL
O20070516000309 FL Part A Provider - Hospital 5092613570 Practice locations: Macclenny, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013931765. Details of each certification follow.

Hospital certification: CCN 104007

Legal name
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
Doing business as
NORTHEAST FLORIDA STATE HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Psychiatric
Participating since
May 22, 1969
Last certification
Mar 13, 2025
Beds
1,138 (60 certified)
Ownership / control type
State
Organization structure
GovernmentNon-profit
Enrollment address
7487 S State Road 121
Macclenny, FL 32063-5451
Hospital Psychiatric Unit
Hospital subgroups
Psychiatric

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Hospital

Medicare Care Compare
Listed as
Northeast Florida State HospitalCCN 104007 · All quality measures
Type
Psychiatric
Ownership
Government - State
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
No

National Provider Directory

National Provider Directory
Tax ID family
FL Department of Childr9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Locations

100 N Main St
Bldg 1028
Chattahoochee, FL 32324
Phone (904) 330-2215

100 N Main St
Ste 14
Chattahoochee, FL 32324
Phone (850) 663-7590

100 N Main St
Unit 14
Chattahoochee, FL 32324
Phone (850) 663-7802

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Rena Flynn Individual W-2 Managing EmployeeRevenue Director Jun 1, 2005
Diana Nielsen Individual W-2 Managing Employee Jan 3, 2012
Deagan D Watson Individual W-2 Managing EmployeeAd; Dec 9, 2024 100%
Operational/Managerial ControlAdministrator Dec 9, 2024 100%

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Florida State HospitalChattahoochee, FL, CCN 104000 Hospital Operational/Managerial Control (100%) May 8, 2012
Florida State HospitalChattahoochee, FL, CCN 100298 Hospital Operational/Managerial Control (100%) Jan 1, 1990

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 117

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 117

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153872000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1605657600000",
    "number": "1013931765",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7487 S STATE ROAD 121",
            "address_2": "ACCOUNTING DEPARTMENT",
            "city": "MACCLENNY",
            "state": "FL",
            "postal_code": "320635480",
            "telephone_number": "904-259-6211",
            "fax_number": "904-259-7154"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7487 S STATE ROAD 121",
            "address_2": "ACCOUNTING DEPARTMENT",
            "city": "MACCLENNY",
            "state": "FL",
            "postal_code": "320635451",
            "telephone_number": "904-259-6211",
            "fax_number": "904-259-7154"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-26",
        "last_updated": "2020-11-18",
        "certification_date": "2020-11-18",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "LINDA",
        "authorized_official_middle_name": "G.",
        "authorized_official_title_or_position": "HOSPITAL ADMINISTRATOR",
        "authorized_official_telephone_number": "904-330-2001",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "283Q00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Hospital",
            "state": "FL",
            "license": "4004",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "026002900",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Northeast Florida State Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Northeast Florida State Hospital",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Macclenny, FL

Sources for this page

Verify at the official NPI Registry.