Provider Demographics
NPI:1639237225
Name:REDDOUT, JEFFREY WALTER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WALTER
Last Name:REDDOUT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ORCHID SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-1678
Mailing Address - Country:US
Mailing Address - Phone:863-326-6419
Mailing Address - Fax:863-326-5640
Practice Address - Street 1:400 ORCHID SPRINGS DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-1678
Practice Address - Country:US
Practice Address - Phone:863-326-6419
Practice Address - Fax:863-326-5640
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5052103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59522Medicare ID - Type Unspecified