Provider Demographics
NPI:1033772405
Name:WOODS III, JESSE WILLARD
Entity Type:Individual
Prefix:
First Name:JESSE WILLARD
Middle Name:
Last Name:WOODS III
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TIGER D
Other - Middle Name:
Other - Last Name:RAVEN-MELCHIZ EL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1410 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-3870
Mailing Address - Country:US
Mailing Address - Phone:215-258-3481
Mailing Address - Fax:
Practice Address - Street 1:1410 N 31ST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-3870
Practice Address - Country:US
Practice Address - Phone:215-258-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-20
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X, 171M00000X, 172V00000X, 174200000X, 344600000X, 347E00000X, 372600000X, 347C00000X
PA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes347C00000XTransportation ServicesPrivate VehicleGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health Worker
No174200000XOther Service ProvidersMeals
No344600000XTransportation ServicesTaxiGroup - Multi-Specialty
No347E00000XTransportation ServicesTransportation Broker
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty