Provider Demographics
NPI:1104299767
Name:GROWUP
Entity type:Organization
Organization Name:GROWUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LEELA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:267-273-8041
Mailing Address - Street 1:345 LEVERINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 W MAIN ST
Practice Address - Street 2:SUITE 435
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2019
Practice Address - Country:US
Practice Address - Phone:267-273-8041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017033103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty