Provider Demographics
NPI:1497804900
Name:WEITZEN, JED H (PHD)
Entity Type:Individual
Prefix:DR
First Name:JED
Middle Name:H
Last Name:WEITZEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 N TIOGA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4229
Mailing Address - Country:US
Mailing Address - Phone:607-273-6946
Mailing Address - Fax:607-256-1680
Practice Address - Street 1:416 N TIOGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4229
Practice Address - Country:US
Practice Address - Phone:607-273-6946
Practice Address - Fax:607-256-1680
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8507103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical