Healthcare Provider Details

I. General information

NPI: 1508190158
Provider Name (Legal Business Name): JORDAN FREDERICK LIEF PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N MONROE ST
MEDIA PA
19063-2908
US

IV. Provider business mailing address

407 KENT RD.
BALA CYNWYD PA
19004
UM

V. Phone/Fax

Practice location:
  • Phone: 610-804-5106
  • Fax:
Mailing address:
  • Phone: 610-804-5106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016639
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: