MEDICARE: DR. JAY ALLEN SUPNICK 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	103T00000X	Psychologist	8678	NY

General Provider Information

NPI Number	:	1699717280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAY ALLEN SUPNICK PH.D.

Provider Business Mailing Address
First Line	:	448 WHITE SPRUCE BLVD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14623-1608
Country	:	US
Telephone Number	:	585-424-5680
Fax Number	:

Provider Business Practice Location Address
First Line	:	448 WHITE SPRUCE BLVD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14623-1608
Country	:	US
Telephone Number	:	585-424-5680
Fax Number	:

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

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	02/24/2011

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