Basic Information
| Provider Information | |||||||||
| NPI: | 1649782277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEDTAOTAO | ||||||||
| FirstName: | JAMIE-ANN | ||||||||
| MiddleName: | U | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 OAK RIDGE PL | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324085201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508147271 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 E 15TH ST | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324055412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505224485 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2017 | ||||||||
| LastUpdateDate: | 11/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH15448 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.