Provider Demographics
NPI:1073767208
Name:REID, JENNIFER GROSSMAN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GROSSMAN
Last Name:REID
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYN
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3535 MARKET ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3309
Mailing Address - Country:US
Mailing Address - Phone:215-746-6700
Mailing Address - Fax:
Practice Address - Street 1:3535 MARKET ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3309
Practice Address - Country:US
Practice Address - Phone:215-746-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4522532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1083860Medicaid
CA0A1083860Medicaid