MEDICARE: KAYLA JEAN JARRED PSYCHOLOGY ASSISTANT

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
2	103T00000X	Psychologist	PSY-005660	AZ

General Provider Information

NPI Number	:	1912553314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA JEAN JARRED PSYCHOLOGY ASSISTANT

Provider Business Mailing Address
First Line	:	PO BOX 748465
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-8465
Country	:	US
Telephone Number	:	855-284-7483
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 E MISSOURI AVE STE 340
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2753
Country	:	US
Telephone Number	:	855-284-7483
Fax Number	:

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

Provider Enumeration Date	:	08/13/2019
Last Update Date	:	06/22/2023

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