Provider Demographics
NPI:1376845933
Name:MARRA, JAIME VICTORIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:VICTORIA
Last Name:MARRA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 DEERWOOD LAKE PKWY STE 101-108
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1177
Mailing Address - Country:US
Mailing Address - Phone:904-479-5120
Mailing Address - Fax:
Practice Address - Street 1:4320 DEERWOOD LAKE PKWY STE 101-108
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1177
Practice Address - Country:US
Practice Address - Phone:904-479-5120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8712103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012365400Medicaid
GA003173791AMedicaid
FLHV534ZMedicare PIN