Provider Demographics
NPI:1942619390
Name:LAZARUS, JESSICA RUTSTEIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:RUTSTEIN
Last Name:LAZARUS
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 1:39 OVERHILL RD
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-2248
Mailing Address - Country:US
Mailing Address - Phone:610-405-8569
Mailing Address - Fax:
Practice Address - Street 1:8400 ROOSEVELT BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2081
Practice Address - Country:US
Practice Address - Phone:215-333-7562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017605103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical