Provider Demographics
NPI:1578389060
Name:EVANS, JUANITA (MS)
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2481 78TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-1824
Mailing Address - Country:US
Mailing Address - Phone:267-481-4023
Mailing Address - Fax:
Practice Address - Street 1:610 OLD YORK ROAD
Practice Address - Street 2:SUITE 400
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046
Practice Address - Country:US
Practice Address - Phone:267-481-4023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAPC000656101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health