Provider Demographics
NPI:1902880537
Name:RUFFETT, ANDREW J (PHD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:RUFFETT
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:PO BOX 17809
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-7809
Mailing Address - Country:US
Mailing Address - Phone:904-723-0015
Mailing Address - Fax:904-338-0951
Practice Address - Street 1:3617 CROWN POINT RD
Practice Address - Street 2:STE 6
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-9010
Practice Address - Country:US
Practice Address - Phone:904-613-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003395103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620002997OtherRAILROAD MEDICARE
FL73349OtherBCBS
FL620002997OtherRAILROAD MEDICARE
FLR03886Medicare UPIN