Healthcare Provider Details

I. General information

NPI: 1750088845
Provider Name (Legal Business Name): JESSICA KRAVETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 RIDGE AVE # 1
LATROBE PA
15650-1926
US

IV. Provider business mailing address

1110 RIDGE AVE # 1
LATROBE PA
15650-1926
US

V. Phone/Fax

Practice location:
  • Phone: 724-220-6413
  • Fax:
Mailing address:
  • Phone: 724-220-6413
  • Fax: 999-999-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPC000474
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: