Basic Information
| Provider Information | |||||||||
| NPI: | 1487880480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SACKOR | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7143 RUTLAND ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191491116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157222342 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1235 PINE ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157359379 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2009 | ||||||||
| LastUpdateDate: | 06/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.