Healthcare Provider Details

I. General information

NPI: 1538246053
Provider Name (Legal Business Name): JENNIFER LEE JOHANNES ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 REGENT CT
STATE COLLEGE PA
16801-7965
US

IV. Provider business mailing address

PO BOX 157 185 BEACH STREET
BLANCHARD PA
16826-0157
US

V. Phone/Fax

Practice location:
  • Phone: 800-505-2101
  • Fax: 814-231-1319
Mailing address:
  • Phone: 570-962-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT004010
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: