MEDICARE: LIGHTHOUSE PSYCHOLOGISTS LLC

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	PY7141	FL

General Provider Information

NPI Number	:	1598022451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHTHOUSE PSYCHOLOGISTS LLC

Provider Business Mailing Address
First Line	:	2450 HOLLYWOOD BLVD
Second Line	:	SUITE 200A
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-6619
Country	:	US
Telephone Number	:	954-667-7176
Fax Number	:

Provider Business Practice Location Address
First Line	:	2450 HOLLYWOOD BLVD
Second Line	:	SUITE 200A
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-6619
Country	:	US
Telephone Number	:	954-667-7176
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PATRICIA JAEGERMAN
Credential	:	PSY.D.
Telephone Number	:	954-667-7176

Provider Enumeration Date	:	04/17/2012
Last Update Date	:	03/21/2016

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