Provider Demographics
NPI:1770910812
Name:LIEM, JASPER Y (LCSW)
Entity type:Individual
Prefix:
First Name:JASPER
Middle Name:Y
Last Name:LIEM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 LOCUST ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5453
Mailing Address - Country:US
Mailing Address - Phone:215-985-4448
Mailing Address - Fax:215-985-4952
Practice Address - Street 1:1417 LOCUST STREET
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3989
Practice Address - Country:US
Practice Address - Phone:215-344-1632
Practice Address - Fax:215-564-8606
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0189451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103110671Medicaid
PA103110671Medicaid