Basic Information
| Provider Information | |||||||||
| NPI: | 1104051671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARTMAN | ||||||||
| FirstName: | JESSIE | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | M.S.W | ||||||||
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| Mailing Information | |||||||||
| Address1: | DIAKON FAMILY LIFE SERVICES | ||||||||
| Address2: | 1800 W. MARKET STREET | ||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705249477 | ||||||||
| FaxNumber: | 5709249492 | ||||||||
| Practice Location | |||||||||
| Address1: | DIAKON FAMILY LIFE SERVICES | ||||||||
| Address2: | 435 W. FOURTH STREET | ||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703227873 | ||||||||
| FaxNumber: | 5703228026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2009 | ||||||||
| LastUpdateDate: | 05/28/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1007777400036 | 05 | PA | MEDICAID |