Provider Demographics
NPI:1407511231
Name:COLE-PUCCI, JENNIFER LYNN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:COLE-PUCCI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107-1330
Mailing Address - Country:US
Mailing Address - Phone:518-522-5528
Mailing Address - Fax:
Practice Address - Street 1:1518 WALNUT ST STE 307
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3402
Practice Address - Country:US
Practice Address - Phone:215-625-9655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-06
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019452103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic