Provider Demographics
NPI:1104976976
Name:SOH, JEREMY (PHD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:SOH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 S 17TH ST STE 1508
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6215
Mailing Address - Country:US
Mailing Address - Phone:510-822-6898
Mailing Address - Fax:
Practice Address - Street 1:255 S 17TH ST STE 1508
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6215
Practice Address - Country:US
Practice Address - Phone:510-822-6898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE101Y00000X
CARPS277102L00000X
CARP277102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty