Provider Demographics
NPI:1063837276
Name:EBRAHIMZADEH, JESSICA ERIN (MS)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:ERIN
Last Name:EBRAHIMZADEH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1619
Mailing Address - Country:US
Mailing Address - Phone:860-508-3906
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD FL 3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-349-5473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAGC000156170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS