Provider Demographics
NPI:1740384262
Name:FREMONT, JEFFREY (PHD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:FREMONT
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 1:1264 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4138
Mailing Address - Country:US
Mailing Address - Phone:570-288-8795
Mailing Address - Fax:570-288-3165
Practice Address - Street 1:1264 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-4138
Practice Address - Country:US
Practice Address - Phone:570-288-8795
Practice Address - Fax:570-288-3165
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004172L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA445983OtherHIGHMARK BLUE SHIELD
PA0019683050002Medicaid
PAPS004172LOtherLICENSE NUMBER
PA0019683050002Medicaid