| National Provider Identifier [NPI]: | 1831327196 |
| Last Name Of The Provider | TEITSMA |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | PSY.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1616 PONTE LEONE LN |
| Street Address 2 Of The Provider | |
| City Of The Provider | LEAGUE CITY |
| Zip Code Of The Provider | 775735067 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Clinical Psychologist |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 4 |
| Number Of Services | 4597 |
| Number Of Medicare Beneficiaries | 145 |
| Total Submitted Charge Amount | 526050 |
| Total Medicare Allowed Amount | 381072.32 |
| Total Medicare Payment Amount | 292477.15 |
| Total Medicare Standardized Payment Amount | 289365.05 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 4 |
| Number Of Medical Services | 4597 |
| Number Of Medicare Beneficiaries With Medical Services | 145 |
| Total Medical Submitted Charge Amount | 526050 |
| Total Medical Medicare Allowed Amount | 381072.32 |
| Total Medical Medicare Payment Amount | 292477.15 |
| Total Medical Medicare Standardized Payment Amount | 289365.05 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 23 |
| Number Of Beneficiaries Age 65 to 74 | 41 |
| Number Of Beneficiaries Age 75 to 84 | 45 |
| Number Of Beneficiaries Age Greater 84 | 36 |
| Number Of Female Beneficiaries | 88 |
| Number Of Male Beneficiaries | 57 |
| Number Of Non Hispanic White Beneficiaries | 100 |
| Number Of Black or African American Beneficiaries | 23 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | 75 |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 60 |
| Percent Of With Chronic Kidney Disease | 44 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 27 |
| Percent Of With Depression | 75 |
| Percent Of With Diabetes | 61 |
| Percent Of With Hyperlipidemia | 54 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 52 |
| Percent Of With Osteoporosis | 14 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 59 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 52 |
| Percent Of With Stroke | 20 |
| Average HCC Risk Score Of Beneficiaries | 2.8344 |