Provider Demographics
NPI:1134576341
Name:JAYAKRISHNAN, JAITHRA
Entity type:Individual
Prefix:
First Name:JAITHRA
Middle Name:
Last Name:JAYAKRISHNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 RISING SUN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-2719
Mailing Address - Country:US
Mailing Address - Phone:347-777-7353
Mailing Address - Fax:267-332-5175
Practice Address - Street 1:4301 RISING SUN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-2719
Practice Address - Country:US
Practice Address - Phone:267-296-7231
Practice Address - Fax:267-332-5175
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NJ37PC00829300101YP2500X
PAPC009108101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional