Basic Information
| Provider Information | |||||||||
| NPI: | 1720183783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLPER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 JOHN F KENNEDY BLVD | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191037421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2679770850 | ||||||||
| FaxNumber: | 2153226067 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 JOHN F KENNEDY BLVD | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191037421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2679770850 | ||||||||
| FaxNumber: | 2153226067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 103TC0700X | PS005921L | PA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 668005 | 01 | PA | PA BLUE SHIELD | OTHER | 0500938000 | 01 | PA | PERSONAL CHOICE | OTHER |