Healthcare Provider Details

I. General information

NPI: 1770632242
Provider Name (Legal Business Name): JENNIFER MARYNIAK ATC, MED., CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SHARP & FRANCIS STREETS
LAURELDALE PA
19605
US

IV. Provider business mailing address

2 MUSKET LN
SHILLINGTON PA
19607-9541
US

V. Phone/Fax

Practice location:
  • Phone: 610-921-8078
  • Fax: 610-921-7922
Mailing address:
  • Phone: 610-921-8078
  • Fax: 610-921-7922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT001529A
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: