Provider Demographics
NPI:1881029635
Name:JEFFERSON, SUSAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:JEFFERSON
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 1:300 BRIGHTON AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:15074
Mailing Address - Country:US
Mailing Address - Phone:724-709-6005
Mailing Address - Fax:
Practice Address - Street 1:300 BRIGHTON AVE STE 110
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:PA
Practice Address - Zip Code:15074
Practice Address - Country:US
Practice Address - Phone:724-709-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017703103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical