Provider Demographics
NPI:1154689826
Name:ANDERSON, JESSICA (PSYD, NCSP)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PSYD, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 HARRISON ST
Mailing Address - Street 2:21E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-2742
Mailing Address - Country:US
Mailing Address - Phone:347-749-0348
Mailing Address - Fax:
Practice Address - Street 1:1616 WALNUT ST
Practice Address - Street 2:2108
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-5313
Practice Address - Country:US
Practice Address - Phone:347-749-0348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ562042103TS0200X
NY1189167103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool