Provider Demographics
NPI:1114341419
Name:LATHAM, JESSICA (MED)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:LATHAM
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2778 TOLBUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2112
Mailing Address - Country:US
Mailing Address - Phone:847-532-1366
Mailing Address - Fax:
Practice Address - Street 1:4 NESHAMINY INTERPLEX DR STE 202
Practice Address - Street 2:
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6940
Practice Address - Country:US
Practice Address - Phone:215-332-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst