Provider Demographics
NPI:1427209451
Name:DUBOIS, JAYNE M (PHD)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:M
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JAYNE
Other - Middle Name:M
Other - Last Name:FIEDLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7431 114TH AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-5119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6110 SHALLOWFORD RD
Practice Address - Street 2:C/O CRC
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1894
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001925103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508707Medicaid
TN36867421Medicare PIN