Healthcare Provider Details

I. General information

NPI: 1164796652
Provider Name (Legal Business Name): JANE ELLEN HIGHAM PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 ERIE BLVD W
SYRACUSE NY
13204-2445
US

IV. Provider business mailing address

620 ERIE BLVD W
SYRACUSE NY
13204-2445
US

V. Phone/Fax

Practice location:
  • Phone: 315-425-4400
  • Fax:
Mailing address:
  • Phone: 315-425-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number019483
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: