Provider Demographics
NPI:1447893227
Name:VERGHESE, JACI (PHD)
Entity type:Individual
Prefix:DR
First Name:JACI
Middle Name:
Last Name:VERGHESE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 CRIMSON LN
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-8745
Mailing Address - Country:US
Mailing Address - Phone:717-468-2619
Mailing Address - Fax:
Practice Address - Street 1:134 CRIMSON LN
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-8745
Practice Address - Country:US
Practice Address - Phone:717-468-2619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC006931101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health