Healthcare Provider Details

I. General information

NPI: 1427471663
Provider Name (Legal Business Name): JENNIFER S. SANDERSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12955 BISCAYNE BLVD SUITE 203
NORTH MIAMI FL
33181-2037
US

IV. Provider business mailing address

9495 EVERGREEN PL APT. 301
DAVIE FL
33324-4353
US

V. Phone/Fax

Practice location:
  • Phone: 954-465-1633
  • Fax:
Mailing address:
  • Phone: 954-294-7428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY8878
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPY8878
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: