Healthcare Provider Details

I. General information

NPI: 1154689826
Provider Name (Legal Business Name): JESSICA ANDERSON PSY.D, NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 WALNUT ST 2108
PHILADELPHIA PA
19103-5313
US

IV. Provider business mailing address

40 HARRISON ST 21E
NEW YORK NY
10013-2742
US

V. Phone/Fax

Practice location:
  • Phone: 347-749-0348
  • Fax:
Mailing address:
  • Phone: 347-749-0348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number562042
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1189167
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: