Healthcare Provider Details

I. General information

NPI: 1649615170
Provider Name (Legal Business Name): JESSICA LAX PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10541 DRUMMOND RD
PHILADELPHIA PA
19154
US

IV. Provider business mailing address

2005 CABOT BLVD W
LANGHORNE PA
19047-1885
US

V. Phone/Fax

Practice location:
  • Phone: 215-612-7573
  • Fax: 215-632-6426
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS018819
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: