Provider Demographics
NPI:1265093579
Name:JESSE WILLARD WOODS III
Entity type:Organization
Organization Name:JESSE WILLARD WOODS III
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIGER D.
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVEN-MELCHIZ EL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-435-4203
Mailing Address - Street 1:1410 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-3870
Mailing Address - Country:US
Mailing Address - Phone:215-258-4815
Mailing Address - Fax:
Practice Address - Street 1:1410 N 31ST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-3870
Practice Address - Country:US
Practice Address - Phone:215-258-4815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty