Healthcare Provider Details

I. General information

NPI: 1760688204
Provider Name (Legal Business Name): JENNIFER BRAE SNAVELY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 LOGAN AVE
STATE COLLEGE PA
16801-4623
US

IV. Provider business mailing address

PO BOX 791
NORTHBROOK IL
60065-0791
US

V. Phone/Fax

Practice location:
  • Phone: 814-206-9944
  • Fax: 224-235-4652
Mailing address:
  • Phone: 847-593-8460
  • Fax: 224-235-4652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT011584
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0S014357
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: