Provider Demographics
NPI:1174241020
Name:SUPPERER, JESSICA LEE (LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:SUPPERER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 STANTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1618
Mailing Address - Country:US
Mailing Address - Phone:215-260-3465
Mailing Address - Fax:
Practice Address - Street 1:2291 CABOT BLVD W
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-1806
Practice Address - Country:US
Practice Address - Phone:215-642-3230
Practice Address - Fax:215-642-3234
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC014795101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional