MEDICARE: JENNIFER BETANCUR LCSW

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	1041C0700X	Clinical Social Worker	SW 12475	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SW 12475	OTHER	FL	LCSW LICENSE NUMBER

General Provider Information

NPI Number	:	1164815023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER BETANCUR LCSW

Provider Business Mailing Address
First Line	:	4008 LADY PALM CT
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-2383
Country	:	US
Telephone Number	:	813-777-7407
Fax Number	:

Provider Business Practice Location Address
First Line	:	4008 LADY PALM CT
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-2383
Country	:	US
Telephone Number	:	813-777-7407
Fax Number	:

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

Provider Enumeration Date	:	03/16/2015
Last Update Date	:	02/09/2017

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