Healthcare Provider Details

I. General information

NPI: 1972745644
Provider Name (Legal Business Name): JENNIFER GITTLEMAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2009
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S GODDARD BLVD
KING OF PRUSSIA PA
19406-2922
US

IV. Provider business mailing address

PO BOX 99371
FORT WORTH TX
76199-0371
US

V. Phone/Fax

Practice location:
  • Phone: 610-337-3232
  • Fax:
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberQ6419
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ6419
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS020303
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: