Healthcare Provider Details

I. General information

NPI: 1144097684
Provider Name (Legal Business Name): JACOB KOFFLER LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 SANSOM ST FL 11
PHILADELPHIA PA
19103-5245
US

IV. Provider business mailing address

1116 S 47TH ST APT 2
PHILADELPHIA PA
19143-3615
US

V. Phone/Fax

Practice location:
  • Phone: 914-261-4370
  • Fax:
Mailing address:
  • Phone: 914-261-4370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW141020
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: