1770910812 NPI number — JASPER Y LIEM LCSW

Table of content: JASPER Y LIEM LCSW (NPI 1770910812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770910812 NPI number — JASPER Y LIEM LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIEM
Provider First Name:
JASPER
Provider Middle Name:
Y
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

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:
1770910812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1233 LOCUST ST
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19107-5453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-985-4448
Provider Business Mailing Address Fax Number:
215-985-4952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1417 LOCUST STREET
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19102-3989
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-344-1632
Provider Business Practice Location Address Fax Number:
215-564-8606
Provider Enumeration Date:
10/03/2013

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 , with the licence number:  CW018945 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103110671 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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