MEDICARE: DR. LAURA B JAYCOX PSYD

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	103T00000X	Psychologist	2004029371	MO

General Provider Information

NPI Number	:	1285968651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA B JAYCOX PSYD

Provider Business Mailing Address
First Line	:	1307 AVONDALE SPRING DR
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63368-7995
Country	:	US
Telephone Number	:	636-795-0738
Fax Number	:

Provider Business Practice Location Address
First Line	:	1307 AVONDALE SPRING DR
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63368-7995
Country	:	US
Telephone Number	:	636-795-0738
Fax Number	:

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

Provider Enumeration Date	:	10/01/2009
Last Update Date	:	10/01/2009

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