MEDICARE: THOMAS JEFFERSON UNIVERSITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist
2	251K00000X	Public Health or Welfare Agency	820023	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467547968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS JEFFERSON UNIVERSITY

Provider Business Mailing Address
First Line	:	1021 S 21ST ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-2634
Country	:	US
Telephone Number	:	215-890-6277
Fax Number	:	215-790-9947

Provider Business Practice Location Address
First Line	:	1021 SOUTH 21ST STREET
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146
Country	:	US
Telephone Number	:	215-735-5979
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. SARA M SHANE
Credential	:	PSY.D.
Telephone Number	:	215-890-6289

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	01/07/2026

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Directions to “THOMAS JEFFERSON UNIVERSITY ” Practice Location

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