Basic Information
| Provider Information | |||||||||
| NPI: | 1770910812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIEM | ||||||||
| FirstName: | JASPER | ||||||||
| MiddleName: | Y | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 LOCUST ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159854448 | ||||||||
| FaxNumber: | 2159854952 | ||||||||
| Practice Location | |||||||||
| Address1: | 1417 LOCUST STREET | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191023989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153441632 | ||||||||
| FaxNumber: | 2155648606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CW018945 | PA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 103110671 | 05 | PA | MEDICAID |