Provider Demographics
NPI:1639532237
Name:JACQUELINE JAFFE O'DUOR, LLC
Entity Type:Organization
Organization Name:JACQUELINE JAFFE O'DUOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:JAFFE
Authorized Official - Last Name:O'DUOR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:267-329-9393
Mailing Address - Street 1:5109 KINGSESSING AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-4327
Mailing Address - Country:US
Mailing Address - Phone:267-329-9393
Mailing Address - Fax:
Practice Address - Street 1:2305 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-2515
Practice Address - Country:US
Practice Address - Phone:267-329-9393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA017676104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA12535207OtherCAQH ID