MEDICARE: MRS. SANDRA JACOMET

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	103TS0200X	School Psychologist	OK1000942	OK

General Provider Information

NPI Number	:	1770982860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA JACOMET

Provider Business Mailing Address
First Line	:	4400 N UNION RD
Second Line	:
City	:	TROTWOOD
State	:	OH
Zip	:	45426-3706
Country	:	US
Telephone Number	:	937-854-4511
Fax Number	:

Provider Business Practice Location Address
First Line	:	4400 N UNION RD
Second Line	:
City	:	TROTWOOD
State	:	OH
Zip	:	45426-3706
Country	:	US
Telephone Number	:	937-854-4511
Fax Number	:

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

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	08/14/2014

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Directions to “ MRS. SANDRA JACOMET ” Practice Location

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