Healthcare Provider Details

I. General information

NPI: 1124558358
Provider Name (Legal Business Name): JESSICA WEBSTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4003 1ST AVE STE A
LAFAYETTE HILL PA
19444-1401
US

IV. Provider business mailing address

4003 1ST AVE STE A
LAFAYETTE HILL PA
19444-1401
US

V. Phone/Fax

Practice location:
  • Phone: 267-973-7529
  • Fax:
Mailing address:
  • Phone: 267-973-7529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPC004174
License Number StatePA

VIII. Authorized Official

Name: JESSICA L WEBSTER
Title or Position: SOLE PROPRIETOR
Credential: LPC
Phone: 267-973-7529