MEDICARE: DR. JAIME VICTORIA MARRA PH.D.

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	PY8712	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376845933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAIME VICTORIA MARRA PH.D.

Provider Business Mailing Address
First Line	:	4320 DEERWOOD LAKE PKWY STE 101-108
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-1177
Country	:	US
Telephone Number	:	904-479-5120
Fax Number	:

Provider Business Practice Location Address
First Line	:	4320 DEERWOOD LAKE PKWY STE 101-108
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-1177
Country	:	US
Telephone Number	:	904-479-5120
Fax Number	:

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

Provider Enumeration Date	:	12/02/2010
Last Update Date	:	11/15/2018

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