Provider Demographics
NPI:1629058870
Name:EIBERSON, JEFFREY LAWRENCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LAWRENCE
Last Name:EIBERSON
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 1:1326 SPRUCE ST
Mailing Address - Street 2:SUITE #1905
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5826
Mailing Address - Country:US
Mailing Address - Phone:215-546-1767
Mailing Address - Fax:
Practice Address - Street 1:1326 SPRUCE ST
Practice Address - Street 2:SUITE #1905
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5826
Practice Address - Country:US
Practice Address - Phone:215-546-1767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA LIC. #PS002959L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA246945000OtherMAGELLAN HEALTH CARE
PA4365980OtherAETNA HEALTH CARE
PA438240OtherHIGHMARK BLUE SHEILD
PA0063120000OtherBC PERSONAL CHOICE
PA438240Medicare ID - Type Unspecified
PA438240OtherHIGHMARK BLUE SHEILD