Organization
UNIVERSITY OF PENN-MEDICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHANTE L JACKSON DO (ENROLLMENT COOR)
(215) 662-6187
Entity
Organization
Contact information
Practice address
3535 MARKET ST, 3RD FLOOR, PHILADELPHIA, PA 19104-3309
(215) 746-6700
Mailing address
3535 MARKET ST, 3RD FLOOR, PHILADELPHIA, PA 19104-3309
(215) 746-6700
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
—
PA
103TR0400X
Rehabilitation Psychologist
—
PA
104100000X
Social Worker
—
PA
1041C0700X
Clinical Social Worker
—
—
106H00000X
Marriage & Family Therapist
—
—
2084N0402X
Neurology with Special Qualifications in Child Neurology Physician
—
PA
2084P0800X
Psychiatry Physician
Primary
—
PA
2084P0802X
Addiction Psychiatry Physician
—
PA
2084P0804X
Child & Adolescent Psychiatry Physician
—
PA
2084P0805X
Geriatric Psychiatry Physician
—
PA
Other
Enumeration date
12/29/2014
Last updated
11/20/2020
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