Provider Demographics
NPI:1619953361
Name:GRAND, JEFFREY S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:GRAND
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 1:8400 ROOSEVELT BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2081
Mailing Address - Country:US
Mailing Address - Phone:215-901-8791
Mailing Address - Fax:215-333-7563
Practice Address - Street 1:8400 ROOSEVELT BLVD STE 206
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2081
Practice Address - Country:US
Practice Address - Phone:215-901-8791
Practice Address - Fax:215-333-7563
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015842103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P32054Medicare UPIN
P32054Medicare UPIN