Provider Demographics
NPI:1659846475
Name:PEMBLETON, JACLYN DEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:DEAN
Last Name:PEMBLETON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 S 17TH STREET
Mailing Address - Street 2:SUITE 1705
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103
Mailing Address - Country:US
Mailing Address - Phone:215-671-6200
Mailing Address - Fax:
Practice Address - Street 1:255 S 17TH STREET
Practice Address - Street 2:SUITE 1705
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103
Practice Address - Country:US
Practice Address - Phone:267-861-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018637103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical