Healthcare Provider Details

I. General information

NPI: 1780886184
Provider Name (Legal Business Name): CENTER FOR PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 COULTER AVE
ARDMORE PA
19003
US

IV. Provider business mailing address

125 COULTER AVE
ARDMORE PA
19003
US

V. Phone/Fax

Practice location:
  • Phone: 610-642-4873
  • Fax: 610-642-4886
Mailing address:
  • Phone: 610-642-4873
  • Fax: 610-642-4886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StatePA

VIII. Authorized Official

Name: DR. JUDITH TEMPLE JACKSON
Title or Position: MANAGER
Credential: PHD
Phone: 610-642-4873