=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780559153
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER FORMAN PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2025
-----------------------------------------------------
Last Update Date | 10/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1709 LANGHORNE NEWTOWN RD STE 1
-----------------------------------------------------
City | LANGHORNE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19047-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-563-8185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 WHITNEY LN
-----------------------------------------------------
City | RICHBORO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18954-1079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-312-0535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS020605
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PS020605
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------