Healthcare Provider Details

I. General information

NPI: 1306767660
Provider Name (Legal Business Name): GANNON MITCHELL JAQUAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5763 ROUTE 958
BEAR LAKE PA
16402-2931
US

IV. Provider business mailing address

5763 ROUTE 958
BEAR LAKE PA
16402-2931
US

V. Phone/Fax

Practice location:
  • Phone: 814-779-1115
  • Fax:
Mailing address:
  • Phone: 814-779-1115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: