Provider Demographics
NPI:1093766123
Name:FERGUSON, JEAN K (MS)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:K
Last Name:FERGUSON
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 1:22 RED LEAF LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-7000
Mailing Address - Country:US
Mailing Address - Phone:717-314-9171
Mailing Address - Fax:717-208-7348
Practice Address - Street 1:719 OLDE HICKORY RD STE A
Practice Address - Street 2:SUITE A
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4985
Practice Address - Country:US
Practice Address - Phone:717-314-9171
Practice Address - Fax:717-208-7348
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006249L103T00000X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA188829OtherVALUE OPTIONS
PA02045902OtherCAPITAL BLUE CROSS