Healthcare Provider Details

I. General information

NPI: 1477093409
Provider Name (Legal Business Name): JENNA SYKEN LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 16TH AVE
PROSPECT PARK PA
19076-1120
US

IV. Provider business mailing address

114 DURFOR ST
PHILADELPHIA PA
19148-4008
US

V. Phone/Fax

Practice location:
  • Phone: 610-237-6410
  • Fax:
Mailing address:
  • Phone: 302-377-9239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberRT006054
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: