MEDICARE: DR. DAWN OLIVIA WITHERSPOON PHD

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	103T00000X	Psychologist	PY 8828	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	:	1619301199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAWN OLIVIA WITHERSPOON PHD

Provider Business Mailing Address
First Line	:	6266 DUPONT STATION COURT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6266 DUPONT STATION CT E
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2567
Country	:	US
Telephone Number	:	904-383-1038
Fax Number	:

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

Provider Enumeration Date	:	09/03/2013
Last Update Date	:	11/05/2013

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