Basic Information
| Provider Information | |||||||||
| NPI: | 1003100512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JARVIS | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHUSTER | ||||||||
| OtherFirstName: | LAUREL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 32537 WEBSTER TRACT | ||||||||
| Address2: | |||||||||
| City: | THERESA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136913207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022708988 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11050 MOUNT BELVEDERE BLVD | ||||||||
| Address2: | BEHAVIORAL HEALTH DEPARTMENT, MEDDAC | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157724850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2011 | ||||||||
| LastUpdateDate: | 06/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0810002101 | VA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.