MEDICARE: KELLY M. JANKE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	021059	NY
2	103G00000X	Clinical Neuropsychologist	PS018668	PA

General Provider Information

NPI Number	:	1104207190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY M. JANKE PHD

Provider Business Mailing Address
First Line	:	3501 CIVIC CENTER BLVD # 10209
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3820
Country	:	US
Telephone Number	:	267-425-0169
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 CIVIC CENTER BLVD # 10209
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3820
Country	:	US
Telephone Number	:	267-425-0169
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2015
Last Update Date	:	03/27/2020

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