Healthcare Provider Details

I. General information

NPI: 1376997452
Provider Name (Legal Business Name): JEFFREY HAGEN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8302 OLD YORK RD SUITE #12
ELKINS PARK PA
19027-1522
US

IV. Provider business mailing address

972 N RANDOLPH ST
PHILADELPHIA PA
19123-1408
US

V. Phone/Fax

Practice location:
  • Phone: 215-885-9700
  • Fax: 215-886-7678
Mailing address:
  • Phone: 267-255-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC008862
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: