Provider Demographics
NPI:1932320116
Name:KNAST, JEROME FRANCIS (PHD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:FRANCIS
Last Name:KNAST
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 1:2227 WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3125
Mailing Address - Country:US
Mailing Address - Phone:215-232-1417
Mailing Address - Fax:856-384-1512
Practice Address - Street 1:133 HEATHER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-3009
Practice Address - Country:US
Practice Address - Phone:215-601-1413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003306L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAKN122749Medicare PIN
PAR06187Medicare UPIN