Provider Demographics
NPI:1972739902
Name:MISCANNON, JODI GERSON (LSW)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:GERSON
Last Name:MISCANNON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E MERMAID LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-3507
Mailing Address - Country:US
Mailing Address - Phone:215-248-7605
Mailing Address - Fax:
Practice Address - Street 1:102 E MERMAID LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-3507
Practice Address - Country:US
Practice Address - Phone:215-248-7605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW010517L252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000015100014Medicare PIN