Provider Demographics
NPI:1336593458
Name:VANN, JAMAL
Entity Type:Individual
Prefix:
First Name:JAMAL
Middle Name:
Last Name:VANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 AVELLA LN
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-1723
Mailing Address - Country:US
Mailing Address - Phone:215-909-1228
Mailing Address - Fax:
Practice Address - Street 1:2233-43 WEST ALLEGHENY AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132
Practice Address - Country:US
Practice Address - Phone:215-909-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker