Healthcare Provider Details

I. General information

NPI: 1952010068
Provider Name (Legal Business Name): JESSICA DEUTSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 11/17/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE FL CTICU2
WYNNEWOOD PA
19096-3450
US

IV. Provider business mailing address

2238 ELLSWORTH ST UNIT 2
PHILADELPHIA PA
19146-2812
US

V. Phone/Fax

Practice location:
  • Phone: 484-476-2000
  • Fax:
Mailing address:
  • Phone: 724-961-9202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA064114
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: