Healthcare Provider Details

I. General information

NPI: 1104976976
Provider Name (Legal Business Name): JEREMY SOH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S 17TH ST STE 1508
PHILADELPHIA PA
19103-6215
US

IV. Provider business mailing address

255 S 17TH ST STE 1508
PHILADELPHIA PA
19103-6215
US

V. Phone/Fax

Practice location:
  • Phone: 510-822-6898
  • Fax:
Mailing address:
  • Phone: 510-822-6898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberNONE
License Number State
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberRPS277
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberRP277
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: