Healthcare Provider Details

I. General information

NPI: 1164676151
Provider Name (Legal Business Name): JENNIFER TWICHELL JOHNSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 S ALLEN ST STE 102
STATE COLLEGE PA
16801-5923
US

IV. Provider business mailing address

1256 S GARNER ST
STATE COLLEGE PA
16801-6326
US

V. Phone/Fax

Practice location:
  • Phone: 814-308-9067
  • Fax: 814-308-9073
Mailing address:
  • Phone: 814-954-4939
  • Fax: 814-308-9073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW016079
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: