Provider Demographics
NPI:1104986454
Name:WEISSMAN, JAY IRA (PHD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:IRA
Last Name:WEISSMAN
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 1:12B SMEDLEY LN
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-3206
Mailing Address - Country:US
Mailing Address - Phone:610-356-3724
Mailing Address - Fax:610-658-0927
Practice Address - Street 1:12B SMEDLEY LN
Practice Address - Street 2:SUITE 1
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-3206
Practice Address - Country:US
Practice Address - Phone:610-356-3724
Practice Address - Fax:610-658-0927
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS 005215 L103TC0700X
DEB10000503103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0089393000OtherPERSONAL CHOICE
DE1000032392Medicaid
2547468OtherAETNA
50294OtherCHRISTIANA CARE
628075OtherANTHEM BLUE CROSS SHIELD
0089393000OtherKEYSTONE HEALTH PLAN EAST
0089393000OtherAMERIHEALTH
DE1000033857Medicaid
234431OtherCOMPSYCH
020720PHDOtherDE BLUE CROSS SHIELD
50294OtherCHRISTIANA CARE
234431OtherCOMPSYCH
0089393000OtherPERSONAL CHOICE