Organization Name: | GROWUP |
NPI Number: | 1104299767 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | LEELA JACKSON (LICENSED CLINICAL PSYCHOLOGIST) |
Mailing Address: | 100 W Main St Suite 435 Lansdale |
State: | PA US |
Postal Code: | 194462019 |
Phone Number: | 2672738041 |
Fax Number: | |
NPI Enumeration Date: | 11/04/2015 |
NPI Last Update Date: | 11/04/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | PS017033 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | PA |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |