MEDICARE: JACKIE TWITCHELL, PSY.D., P.A.

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	PY5030	FL

General Provider Information

NPI Number	:	1750681268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKIE TWITCHELL, PSY.D., P.A.

Provider Business Mailing Address
First Line	:	8192 COLLEGE PKWY
Second Line	:	BLDG A, STE 21
City	:	FORT MYERS
State	:	FL
Zip	:	33919-5175
Country	:	US
Telephone Number	:	239-275-9353
Fax Number	:	239-466-3390

Provider Business Practice Location Address
First Line	:	8192 COLLEGE PKWY
Second Line	:	BLDG A, STE 21
City	:	FORT MYERS
State	:	FL
Zip	:	33919-5175
Country	:	US
Telephone Number	:	239-275-9353
Fax Number	:	239-466-3390

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JACKIE A TWITCHELL
Credential	:	PSY.D.
Telephone Number	:	239-275-9353

Provider Enumeration Date	:	10/31/2010
Last Update Date	:	12/02/2010

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