Provider Demographics
NPI:1265981963
Name:BACK, JANE (LMCSW)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:BACK
Suffix:
Gender:F
Credentials:LMCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 KINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4011
Mailing Address - Country:US
Mailing Address - Phone:347-377-1855
Mailing Address - Fax:
Practice Address - Street 1:850 W LANCASTER AVE
Practice Address - Street 2:2ND FLOORD
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3220
Practice Address - Country:US
Practice Address - Phone:610-520-1510
Practice Address - Fax:610-520-1517
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0190491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical