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NPI Code Detail

MEDICARE: JASON BOOTHE

MEDICARE: JASON BOOTHE
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
1103T00000XPsychologist32415TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11039619OTHERBLUELINK
28581BHOTHERBCBS

General Provider Information

NPI Number : 1538162722
Entity Type Code : Individual
Provider Name (Legal Business Name) : JASON BOOTHE
Provider Business Mailing Address
First Line : 4310 JAMES CASEY ST
Second Line : BLDG 2
City : AUSTIN
State : TX
Zip : 78745-1120
Country : US
Telephone Number : 512-416-7246
Fax Number : 512-416-6791
Provider Business Practice Location Address
First Line : 4310 JAMES CASEY ST
Second Line : BLDG 2
City : AUSTIN
State : TX
Zip : 78745-1120
Country : US
Telephone Number : 512-416-7246
Fax Number : 512-416-6791
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2005
Last Update Date : 07/08/2007

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Directions to “ JASON BOOTHE ” Practice Location

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