Provider Demographics
NPI:1225262223
Name:RICHARD, JACQUELINE NICOLE (MS)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:RICHARD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:NICOLE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:2140 SAINT VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-1333
Mailing Address - Country:US
Mailing Address - Phone:610-608-7737
Mailing Address - Fax:215-333-3162
Practice Address - Street 1:2140 SAINT VINCENT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1333
Practice Address - Country:US
Practice Address - Phone:610-608-7737
Practice Address - Fax:215-333-3162
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103K00000XOtherHEALTH CARE PROVIDER TAXONOMY CODE SET