MEDICARE: MS. JACLYN LIZZETTE INFANZON M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	IMH 6774	FL

General Provider Information

NPI Number	:	1043545999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACLYN LIZZETTE INFANZON M.S.

Provider Business Mailing Address
First Line	:	1010 1ST ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33701-1808
Country	:	US
Telephone Number	:	727-501-4553
Fax Number	:	727-865-5178

Provider Business Practice Location Address
First Line	:	1010 1ST ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33701-1808
Country	:	US
Telephone Number	:	727-501-4553
Fax Number	:	727-865-5178

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2009
Last Update Date	:	10/09/2009

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