MEDICARE: JISSENIA PEREZ MA

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	103TC1900X	Counseling Psychologist	3796	PR

General Provider Information

NPI Number	:	1326390329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JISSENIA PEREZ MA

Provider Business Mailing Address
First Line	:	14008 SAULK CT APT 137
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-3943
Country	:	US
Telephone Number	:	813-420-2682
Fax Number	:

Provider Business Practice Location Address
First Line	:	14008 SAULK CT APT 137
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-3943
Country	:	US
Telephone Number	:	813-420-2682
Fax Number	:

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

Provider Enumeration Date	:	10/15/2012
Last Update Date	:	10/15/2012

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