MEDICARE: DR. GABRIEL JASSO PH.D

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	103TC0700X	Clinical Psychologist	36112	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	36112	OTHER	TX	LICENSE

General Provider Information

NPI Number	:	1154738516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GABRIEL JASSO PH.D

Provider Business Mailing Address
First Line	:	12800 PRESTON RD
Second Line	:	SUITE 101
City	:	DALLAS
State	:	TX
Zip	:	75230-1365
Country	:	US
Telephone Number	:	972-789-9600
Fax Number	:	972-789-9607

Provider Business Practice Location Address
First Line	:	12800 PRESTON RD
Second Line	:	SUITE 101
City	:	DALLAS
State	:	TX
Zip	:	75230-1365
Country	:	US
Telephone Number	:	972-789-9600
Fax Number	:	972-789-9607

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

Provider Enumeration Date	:	07/17/2014
Last Update Date	:	04/13/2015

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