Provider Demographics
NPI:1639100647
Name:JAMISON, MARK (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JAMISON
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 1:220 E MERMAID LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-3244
Mailing Address - Country:US
Mailing Address - Phone:610-733-9474
Mailing Address - Fax:
Practice Address - Street 1:220 E MERMAID LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-3244
Practice Address - Country:US
Practice Address - Phone:610-733-9474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS0004049L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA195546000OtherMIS NUMBER MAGELLAN