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General NPI Number Information
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NPI Number | 1932332012
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Entity Type | Individual
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Provider Name | JAIME BERCUSON M.A., PSY.D.
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Gender | Female
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Dates
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Enumeration Date | 08/24/2009
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Last Update Date | 11/10/2020
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Provider Practice Location Address
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Address Line | 1389 CENTER DR STE 200
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City | PARK CITY
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State | UT
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Zip | 84098-7660
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Country | US
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Telephone | 727-451-9223
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Fax |
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Provider Business Mailing Address
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Address Line | 1389 CENTER DR STE 200
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City | PARK CITY
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State | UT
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Zip | 84098-7660
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Country | US
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Telephone | 727-451-9223
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY26093
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY8969
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 10389140-2501
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License Number State | UT
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