Basic Information
| Provider Information | |||||||||
| NPI: | 1902880537 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUFFETT | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17809 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322457809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047230015 | ||||||||
| FaxNumber: | 9043380951 | ||||||||
| Practice Location | |||||||||
| Address1: | 3617 CROWN POINT RD | ||||||||
| Address2: | STE 6 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322579010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046131450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 09/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PY0003395 | FL | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 620002997 | 01 | FL | RAILROAD MEDICARE | OTHER | 73349 | 01 | FL | BCBS | OTHER |