1568533875 NPI number — MRS. JENNIFER MARIE DIBERT PTA

Table of content: MRS. JENNIFER MARIE DIBERT PTA (NPI 1568533875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568533875 NPI number — MRS. JENNIFER MARIE DIBERT PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIBERT
Provider First Name:
JENNIFER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEAVER
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PTA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568533875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 MILL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16695-9432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-766-2320
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1798 OLD ROUTE 220 N
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
DUNCANSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16635-8341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-696-3400
Provider Business Practice Location Address Fax Number:
814-696-3402
Provider Enumeration Date:
11/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  TE002703L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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