Basic Information
Provider Information | |||||||||
NPI: | 1740218510 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZAVODNICK | ||||||||
FirstName: | JACQUELYN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1655 OAKWOOD DR | ||||||||
Address2: | N122 | ||||||||
City: | NARBERTH | ||||||||
State: | PA | ||||||||
PostalCode: | 190721017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6106689997 | ||||||||
FaxNumber: | 6102965866 | ||||||||
Practice Location | |||||||||
Address1: | 1041 W BRIDGE ST | ||||||||
Address2: | STES 1 & 2, DEVEREUX BENETO CTR COMM SVCS DEVEREUX | ||||||||
City: | PHOENIXVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 19460 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109338110 | ||||||||
FaxNumber: | 6102965866 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | MD015911E | PA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 0005544390339 | 05 | PA |   | MEDICAID |