Healthcare Provider Details

I. General information

NPI: 1710872114
Provider Name (Legal Business Name): JESSICA WOODHEAD
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1086 FRANKLIN ST
JOHNSTOWN PA
15905-4305
US

IV. Provider business mailing address

122 RAVINE AVE
JOHNSTOWN PA
15905-3021
US

V. Phone/Fax

Practice location:
  • Phone: 814-534-9000
  • Fax:
Mailing address:
  • Phone: 724-961-4577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP033077
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN615935
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: