Provider Demographics
NPI:1467174870
Name:WEAVER, JACIE (EDS, NCSP)
Entity Type:Individual
Prefix:
First Name:JACIE
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19952-1050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:313 S 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:DE
Practice Address - Zip Code:19730-2078
Practice Address - Country:US
Practice Address - Phone:302-398-8197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE245206103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool