Provider Demographics
NPI:1104550490
Name:TYLICKI, JESSICA (PHD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:TYLICKI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CLINT MOORE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-5712
Mailing Address - Country:US
Mailing Address - Phone:561-732-7000
Mailing Address - Fax:561-731-2997
Practice Address - Street 1:7000 W PALMETTO PARK RD STE 201
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3430
Practice Address - Country:US
Practice Address - Phone:561-732-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11524103T00000X, 103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical