MEDICARE: JACQUELINE HENRY

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	103TM1800X	Intellectual & Developmental Disabilities Psychologist		FL

General Provider Information

NPI Number	:	1740863935
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE HENRY

Provider Business Mailing Address
First Line	:	7539 REX HILL TRL
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-8768
Country	:	US
Telephone Number	:	407-497-1439
Fax Number	:

Provider Business Practice Location Address
First Line	:	7539 REX HILL TRL
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-8768
Country	:	US
Telephone Number	:	407-497-1439
Fax Number	:

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

Provider Enumeration Date	:	05/04/2021
Last Update Date	:	05/04/2021

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Directions to “ JACQUELINE HENRY ” Practice Location

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