Healthcare Provider Details

I. General information

NPI: 1265070379
Provider Name (Legal Business Name): JEANNINE CICCO BARKER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S 17TH ST STE 2121
PHILADELPHIA PA
19103-6211
US

IV. Provider business mailing address

PO BOX 2401
PHILADELPHIA PA
19147-0401
US

V. Phone/Fax

Practice location:
  • Phone: 215-839-9179
  • Fax:
Mailing address:
  • Phone: 215-839-9179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS018131
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: