MEDICARE: DR. JENNIFER S. LAND 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	PY4855	FL
2	103TC0700X	Clinical Psychologist	PY0004855	FL

General Provider Information

NPI Number	:	1790778934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER S. LAND PHD

Provider Business Mailing Address
First Line	:	PO BOX 918025
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32891-8025
Country	:	US
Telephone Number	:	352-392-4541
Fax Number	:	352-392-7766

Provider Business Practice Location Address
First Line	:	2602 NW 6TH ST
Second Line	:	STE A
City	:	GAINESVILLE
State	:	FL
Zip	:	32609-2944
Country	:	US
Telephone Number	:	352-392-4541
Fax Number	:	352-392-7766

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

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	10/11/2018

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