Healthcare Provider Details

I. General information

NPI: 1538548417
Provider Name (Legal Business Name): JANICE YACKOSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2015
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 N BROAD ST
PHILADELPHIA PA
19140
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-1800
  • Fax: 215-707-3644
Mailing address:
  • Phone: 215-707-1800
  • Fax: 215-707-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD464277
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: