Provider Demographics
NPI:1649615170
Name:LAX, JESSICA (PSYD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:LAX
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 CABOT BLVD W
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-1885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10541 DRUMMOND RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19154
Practice Address - Country:US
Practice Address - Phone:215-612-7573
Practice Address - Fax:215-632-6426
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018819103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA23-1742920Medicaid