MEDICARE: JESSICA DEITCH

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	101YM0800X	Mental Health Counselor	67690	TX

General Provider Information

NPI Number	:	1164847794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA DEITCH

Provider Business Mailing Address
First Line	:	12036 CANTERBURY RD
Second Line	:
City	:	SPRING BRANCH
State	:	TX
Zip	:	78070-7201
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12036 CANTERBURY RD
Second Line	:
City	:	SPRING BRANCH
State	:	TX
Zip	:	78070-7201
Country	:	US
Telephone Number	:	210-601-6507
Fax Number	:

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

Provider Enumeration Date	:	02/18/2014
Last Update Date	:	02/18/2014

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Directions to “ JESSICA DEITCH ” Practice Location

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