Healthcare Provider Details

I. General information

NPI: 1639519424
Provider Name (Legal Business Name): MR. JEFFREY A EVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30207 FRANKFORD SCHOOL RD
FRANKFORD DE
19945-2616
US

IV. Provider business mailing address

30207 FRANKFORD SCHOOL RD
FRANKFORD DE
19945-2616
US

V. Phone/Fax

Practice location:
  • Phone: 302-732-3800
  • Fax: 302-732-1344
Mailing address:
  • Phone: 302-732-3800
  • Fax: 302-732-1344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number66721
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: