Healthcare Provider Details

I. General information

NPI: 1013789908
Provider Name (Legal Business Name): JACQUELINE HEYWARD LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/24/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2052 MATHER WAY # B
ELKINS PARK PA
19027-1033
US

IV. Provider business mailing address

2052 MATHER WAY # B
ELKINS PARK PA
19027-1033
US

V. Phone/Fax

Practice location:
  • Phone: 267-997-7790
  • Fax:
Mailing address:
  • Phone: 267-997-7790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberQ4-0010443
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: