Provider Demographics
NPI:1821446170
Name:KLOSS, JACQUELINE DEMICHELE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:DEMICHELE
Last Name:KLOSS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 MARKET ST STE 670
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3309
Mailing Address - Country:US
Mailing Address - Phone:215-410-8167
Mailing Address - Fax:
Practice Address - Street 1:3535 MARKET ST STE 670
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-410-8167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015430103TB0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral