MEDICARE: DR. JESSICA NICOLE GIFFORD PSY.D., LCP

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	0810003464	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	177813	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1336288125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA NICOLE GIFFORD PSY.D., LCP

Provider Business Mailing Address
First Line	:	2 DRAMMEN CT
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-1000
Country	:	US
Telephone Number	:	757-564-8326
Fax Number	:

Provider Business Practice Location Address
First Line	:	1309 JAMESTOWN RD
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23185-3380
Country	:	US
Telephone Number	:	757-348-3422
Fax Number	:

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

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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