1164415097 NPI number — JENNIFER A HUSELTON MPT

Table of content: JENNIFER A HUSELTON MPT (NPI 1164415097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164415097 NPI number — JENNIFER A HUSELTON MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUSELTON
Provider First Name:
JENNIFER
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NOTTE
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164415097
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 UNION ST STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TITUSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16354-1166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-670-0534
Provider Business Mailing Address Fax Number:
814-670-0653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 W PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16323-1365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-432-7934
Provider Business Practice Location Address Fax Number:
814-432-8680
Provider Enumeration Date:
08/25/2005

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: 225100000X , with the licence number:  PT017337 , 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)

  • Identifier: 12102558 . This is a "CAQH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 101662166 0005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101662166 0006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101662166 0002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1016621660001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001694595 . This is a "HIGHMARK BLUE CROSS/ BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 101662166 0003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 262004 . This is a "HEALTH AMERICA/COVENTRY HEALTH CARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 101662166 0004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101662166 0007 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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