Healthcare Provider Details

I. General information

NPI: 1457930810
Provider Name (Legal Business Name): JACQUELYN MARIE KOHLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELYN MARIE MOLLO

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E BROAD ST
HAZLETON PA
18201-6835
US

IV. Provider business mailing address

2100 MACK BLVD FL 4
ALLENTOWN PA
18103-5622
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-4193
  • Fax:
Mailing address:
  • Phone: 484-884-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD486212
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: