Healthcare Provider Details

I. General information

NPI: 1669824413
Provider Name (Legal Business Name): JAMAL-KALEE FERGUSON SR. LBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 MACDONALD AVE
WYNCOTE PA
19095-2402
US

IV. Provider business mailing address

272 MACDONALD AVE
WYNCOTE PA
19095-2402
US

V. Phone/Fax

Practice location:
  • Phone: 267-767-0662
  • Fax:
Mailing address:
  • Phone: 267-767-0662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: