=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003563297
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE JAFFE MA LPC ATR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2022
-----------------------------------------------------
Last Update Date | 03/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2566 FRANKFORD AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19125-1743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-571-9534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 534 WOODLAND AVE
-----------------------------------------------------
City | CHELTENHAM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19012-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-680-3994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC011414
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------