Provider Demographics
NPI:1750681268
Name:JACKIE TWITCHELL, PSY.D., P.A.
Entity Type:Organization
Organization Name:JACKIE TWITCHELL, PSY.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:TWITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:239-275-9353
Mailing Address - Street 1:8192 COLLEGE PKWY
Mailing Address - Street 2:BLDG A, STE 21
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-5175
Mailing Address - Country:US
Mailing Address - Phone:239-275-9353
Mailing Address - Fax:239-466-3390
Practice Address - Street 1:8192 COLLEGE PKWY
Practice Address - Street 2:BLDG A, STE 21
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-5175
Practice Address - Country:US
Practice Address - Phone:239-275-9353
Practice Address - Fax:239-466-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-31
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5030103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty