Provider Demographics
NPI:1952115255
Name:FRAZIER-JACKSON, ELIJAH NATIA
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:NATIA
Last Name:FRAZIER-JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 RUSCOMBE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-1610
Mailing Address - Country:US
Mailing Address - Phone:215-350-7193
Mailing Address - Fax:
Practice Address - Street 1:221 RUSCOMBE AVE
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-1610
Practice Address - Country:US
Practice Address - Phone:215-350-7193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW139071104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker