Basic Information
| Provider Information | |||||||||
| NPI: | 1861737066 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEIDLE | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 11511 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
| FaxNumber: | 2152557825 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 WISSAHICKON AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191444248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159672130 | ||||||||
| FaxNumber: | 2159672171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2012 | ||||||||
| LastUpdateDate: | 05/23/2016 | ||||||||
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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 | PC005900 | PA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.