Healthcare Provider Details

I. General information

NPI: 1760323265
Provider Name (Legal Business Name): THE REVIVAL ROOM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N SPRING ST STE 130
BELLEFONTE PA
16823-1543
US

IV. Provider business mailing address

301 N SPRING ST STE 130
BELLEFONTE PA
16823-1543
US

V. Phone/Fax

Practice location:
  • Phone: 814-343-1533
  • Fax: 888-253-1993
Mailing address:
  • Phone: 814-343-1533
  • Fax: 888-253-1993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JAYCIE JABCO
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 717-487-8857