Provider Demographics
NPI:1366468134
Name:SHOSTACK, JEFFREY SCOTT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:SHOSTACK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 ARCH ST
Mailing Address - Street 2:APT. 401
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1328
Mailing Address - Country:US
Mailing Address - Phone:215-825-7645
Mailing Address - Fax:
Practice Address - Street 1:246 W STREET RD
Practice Address - Street 2:SUITE 4A
Practice Address - City:WARMINSTER
Practice Address - State:PA
Practice Address - Zip Code:18974-3228
Practice Address - Country:US
Practice Address - Phone:215-825-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008603L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical