1073042743 NPI number — MS. AMY MARIE JERSILD LCSW

Table of content: MS. AMY MARIE JERSILD LCSW (NPI 1073042743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073042743 NPI number — MS. AMY MARIE JERSILD LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JERSILD
Provider First Name:
AMY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073042743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1720 DELANCEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19103-6715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-303-5424
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 WALNUT ST STE 1004
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19107-4721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-590-4766
Provider Business Practice Location Address Fax Number:
215-590-4766
Provider Enumeration Date:
06/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CW01498 . This is a "CLINICAL SOCIAL WORK LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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